Data related to an individual’s insurance coverage for healthcare.

Data Element
Plan Identifier
Description
Business concept used by a health plan to describe its benefit offerings.
Submitted By: Mark Roberts / Leavitt Partners
Data Element Information
Data Element Description Business concept used by a health plan to describe its benefit offerings.
Use Case Description(s)
Use Case Description Administrative and financial transactions are a critical part of health care provisioning and management. There is a need for health care consumers to get access this health data to be able to make better care decisions and manage their health care journey. Making Health Insurance Coverage data available to consumers will enable them to have greater visibility into the costs associated with their health care, identify potential errors, and enable them to plan for their future health care needs taking financial costs into account.
Consumer-directed exchange occurs when a consumer or an authorized caregiver invokes their HIPAA Individual Right of Access (45 CFR 164.524) and requests their digital health information (adjudicated claims and encounter data) from a HIPAA covered entity (CE) – health insurance company or payers via an application or other third-party data steward.
Estimate the breadth of applicability of the use case(s) for this data element All health care insurers (>1,800), third-party application developers, and all consumers of the health care system (>320M)
Link to use case project page http://hl7.org/fhir/us/carin-bb/
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.
http://hl7.org/fhir/us/carin-bb/artifacts.html#5
Additional Specifications HL7® FHIR® US Core Implementation Guide v3.1.1 based on FHIR R4
Current Use Extensively used in production environments
Supporting Artifacts This was part of the CMS Patient Access and Interoperability Rules, which went into effect July 1, 2021. CMS has suggested that industry consider using the CARIN for Blue Button Implementation Guide for the Patient Access API.
https://www.cms.gov/about-cms/health-informatics-and-interoperability-group/faqs
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts While it is not known how many consumers have requested this data electronically, this information is communicated broadly today through other forms. This data is now being required to be communicated electronically through the CMS Patient Access API for which the regulation has suggested that industry consider using the CARIN for Blue Button Implementation Guide for the Patient Access API, we expect this data will be exchanged broadly throughout the health care sector.
https://www.cms.gov/about-cms/health-informatics-and-interoperability-group/faqs
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) Some codes, but not all, are linked to proprietary code standards that may require a license.
Restrictions on Use (e.g. licensing, user fees) Licensed Industry Standard Code Systems

This IG includes value set bindings to code systems that reference industry standard codes which require implementers to purchase a license before the coded concepts can be used. The following information summarizes the set of licensed Code Systems required by this IG and provides links to the information about where to go to obtain a license:

• AMA CPT: The CPT procedure and modifier codes are owned by the American Medical Association.
• X12: CARC (Claim Adjustment Reason Codes are owned by X12..
• NUBC: The NUBC secretariat is the American Hospital Association..
• NUCC: National Uniform Claim Committee (NUCC) is presently maintaining the Taxonomy code set. The codes are free and publically available for download and use. If the use however is “For commercial use, including sales or licensing, a license must be obtained”. It would be appropriate for an app developer to file the license form just like they would for any other code set; however, there is no fee.
• NCPDP: Retail Pharmacy data standards are defined by the NCPDP .
• 3M APR-DRG: AP-DRGs and APR-DRGs are owned by 3M. Use of AP-DRGs and APR-DRGs require a license.

Code Systems Not Requiring Licenses

This IG includes value set bindings to code systems that are industry standard codes available for use without licenses. The following information summarizes the set of Code Systems required by this IG that are available for use:
• ICD-CM Diagnosis Codes (ICD-10-CM): International Statistical Classification of Diseases and Related Health Problems (ICD). This IG will use version 10. The ICD-10-CM code set is maintained by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the United States. It is based on ICD-10, which was developed by the World Health Organization (WHO) and is used internationally a medical classification.
• ICD-Procedure Codes (ICD-PCS): The ICD-10-PCS code set is owned by CMS..
• DRGs.:MS-DRGs are owned by CMS. MS-DRGs are used for the Medicare population.
• HCPCS Level II Procedure and Modifier Codes: Primarily include non-physician products, supplies, and procedures not included in CPT. They are owned by CMS and are available for use.
• NDC (National Drug Codes): The US Federal Drug Administration (FDA) Data Standards Council assigns the first 5 digits of the 11 digit code..
• RARCCodes: The RARC codes are owned by CMS.
Privacy and Security Concerns This data, like any patient data should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data.
Estimate of Overall Burden The data elements in this class are already held by health care payers, anticipated burden of collection of data would be negligible. The CMS rule and Patient Access API already require CMS covered payers to share this data electronically. Many payers covered by the CMS rule have or are already considering making this data available in the same fashion for other lines of business.
ASTP Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by CDC_DSMH_WG on

CDC's comment for inclusion in USCDI v7

CDC supports inclusion of these health insurance related elements to USCDI v7, such as Health Insurance Plan Identifier. The process of completing and submitting a birth certificate includes identification of the principal source of payment for the delivery. It is defined as the primary source of payment for the delivery at the time of delivery. The options reported include private insurance, Medicaid or comparable state program, self-pay or other source of coverage.

Sources: U. S. Standard Certificate of Live Birth (https://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf) (November 2003) (cdc.gov); Facility Worksheet for the Live Birth Certificate (https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf)
 

Log in or register to post comments

FormGuide

Help

1. Optional: Background Text / Cover Letter

The "Optional Background Text / Cover Letter" field provides space for additional context or introductory information related to your comment.

If you wish to provide context, explanation, or an introduction to your comment, enter this information in the field labeled "Optional Background Text / Cover Letter." This is entirely optional and is most useful when submitting multiple related comments or when additional background would help reviewers understand your feedback.

If you are only commenting on a single data class or element, you may leave this field blank.

2. Select the Data Class

To specify which data class your comment addresses:

  1. In the "Data Class" drop-down menu, select the appropriate data class you want to comment on.
  2. If you are providing a general comment that is not specific to a data element, select "General" from the options. Comments with this designation will be displayed on the USCDI landing page.
  3. Note that the Data Class field will automatically populate based on your current location in the platform:
    1. If you are on a data class page, the field will be set to that specific data class
    2. If you are on a data element page, the corresponding data class will be pre-selected
       

3. Select the Data Element

To specify which data element your comment addresses:

  1. In the "Data Element" drop-down menu, select the specific data element you want to comment on.
  2. The drop-down menu will display only the elements available under the data class you selected in the previous step.
  3. You can use the search function within the drop-down to quickly locate a specific data element.
  4. If you are commenting on the data class itself rather than a specific element, you may leave this field blank.

Note: Comments on a specific data element will appear on the respective data element page, while comments on a data class (without a specific element selected) will appear on the landing page for that data class.
 

Data Class and Data Element

Fig 1 The "Data Class" and "Data Element" dropdown menus allow users to specify the exact content they wish to comment on.

4. Optional: Propose New Data Class or Element

If you cannot find the appropriate data class or element for your comment:

  1. Instead of clicking the "Comment On An Existing Data Class Or Element" button, click the adjacent button labeled "Propose a New Data Class or Data Element."
  2. This will redirect you to the ONDEC (ONC New Data Element and Class) Submission System.
  3. In the ONDEC system, follow the provided instructions to submit your proposal for a new data class or element.
  4. Once your proposal is submitted through ONDEC, it will be reviewed separately from the commenting process.
Propose New Data Class or Element

Fig 2 The "Propose a New Data Class or Data Element" button redirects users to the ONDEC Submission System for proposing new data elements not currently available in the system.

5. Complete the Comment Form

Fill out the required fields in the comment form:

Subject: Enter a brief, descriptive title that summarizes your comment. This helps reviewers quickly understand the nature of your feedback.

Comment: In this field, provide the full details of your comment or feedback. Be as clear and specific as possible about your suggestions, concerns, or observations. Include any relevant details that support your position.

6. Optional: Add Additional Comments

If you need to comment on multiple data classes or elements:

  1. After completing your first comment, click the link labeled "Comment on another data element" at the bottom of the form.
  2. A new comment section will appear, allowing you to enter details for your additional comment.
  3. For each additional comment, you must select the appropriate data class and data element from the drop-down menus.
  4. Complete the Subject and Comment fields for your additional comment.
  5. Repeat this process for each additional comment you wish to submit.

Fig 3 The "Comment on another data element" link enables users to create multiple comments addressing different elements within a single submission.

7. Optional: Upload Supporting Files

The platform allows you to upload supporting documentation to enhance your comment:

  • Locate the "File Upload" section at the bottom of the comment form.
  • Click to upload any files (such as PDFs or documents) that provide additional context, evidence, or clarification for your comment.

Important: If you have already entered your comments using the form fields, there is no need to upload duplicate content in PDF format. The file upload feature is intended for supplementary materials only. Please avoid uploading files that contain the same information already provided in your comment text.

Upload Supporting Files

Fig 4 The "File Upload" section permits users to attach supporting documentation that supplements their written comments.

8. Optional: Save and Exit

If you need to pause your work and return to complete your comment later:

  1. Click the "Save and Exit" button at the bottom of the form.
  2. Your comment will be saved as a draft that you can access and complete later.
  3. When you return to the platform, you will see a red triangle with an exclamation mark next to the “Return to saved Comment” button, indicating that you have saved comments in draft status.
  4. Click this button to continue working on your draft.
  5. You will be taken to a review page where you can:
    1. Select "Submit Comment" to officially submit your feedback.
    2. Click "Edit" to return to the comment form and make changes
    3. Select "Discard Draft" to delete the saved draft and start fresh

Fig 5 A red triangle with exclamation mark indicator appears next to the “Return to saved Comment” button when draft comments are saved in the system.

9. Review and Submit

Once you have completed your comment:

  1. Click the "Review and Submit" button at the bottom of the form.
  2. This will take you to a review screen displaying your comment(s) in full.
  3. Review all information for accuracy and completeness.
  4. On this review screen, you have three options: 
    1. Click "Submit Comment" to officially submit your feedback
    2. Click "Edit" to return to the comment form and make changes
    3. Click "Discard Draft" to delete the comment and start fresh
  5. The review screen also includes a "Print" button that allows you to create a printed copy of your comments for your records. 
  6. If you choose to submit, your comment will be recorded in the system and made available for review by the appropriate stakeholders.
Review and Submit

Fig 6 The review screen allows users to verify comment content and make any necessary modifications before final submission.

USCDI Comments

Close

Add a New Comment

Review comment and Submit

Edit
Comment #1
PDF, Doc, Docx
Max Size : 10 MB