@prefix coverage: . @prefix cascade: . @prefix fhir: . @prefix prov: . @prefix owl: . @prefix rdf: . @prefix rdfs: . @prefix xsd: . @prefix dct: . # ============================================================================ # Ontology Metadata # ============================================================================ a owl:Ontology ; owl:imports ; dct:title "Cascade Protocol Coverage Vocabulary"@en ; dct:description "Domain vocabulary for patient-owned insurance, benefits, and financial health data. Layer 2 vocabulary resolving the overlap between checkup:InsuranceInfo (patient-reported) and clinical:CoverageRecord (EHR-imported) with a unified, standardized representation."@en ; dct:creator "Cascade Agentic Labs" ; dct:created "2026-02-18"^^xsd:date ; dct:modified "2026-03-17"^^xsd:date ; owl:versionInfo "1.3" ; rdfs:comment "Insurance and benefits data is cross-cutting: not clinical (it's administrative/financial), not app-specific (any health app benefits from knowing coverage), and contributed by both patient self-report and EHR import. This vocabulary provides a single Layer 2 domain model that both checkup: (Layer 3, patient-reported) and clinical: (Layer 2, EHR-imported) can reference via the mixed namespace pattern. Recommended Pod storage path: /coverage/"@en ; rdfs:seeAlso . # ============================================================================ # Classes # ============================================================================ coverage:InsurancePlan a owl:Class ; rdfs:label "Insurance Plan"@en ; rdfs:comment "An insurance plan the patient is enrolled in. Unifies patient-reported data (from checkup:InsuranceInfo) and EHR-imported data (from clinical:CoverageRecord) into a single standardized representation. Recommended Pod storage: /coverage/plans/{plan-id}.ttl"@en ; rdfs:subClassOf prov:Entity ; rdfs:seeAlso fhir:Coverage . coverage:Deductible a owl:Class ; rdfs:label "Deductible"@en ; rdfs:comment "Annual deductible status and progress tracking for an insurance plan. Enables patients to monitor their progress toward meeting annual deductible limits. Properties for this class will be defined in a future version."@en ; rdfs:subClassOf prov:Entity ; rdfs:seeAlso fhir:ExplanationOfBenefit . coverage:CopaySchedule a owl:Class ; rdfs:label "Copay Schedule"@en ; rdfs:comment "Copay amounts by service category for an insurance plan. Helps patients understand their cost-sharing responsibilities for different types of care. Properties for this class will be defined in a future version."@en ; rdfs:subClassOf prov:Entity . # ============================================================================ # Data Properties - Core Insurance (from checkup:InsuranceInfo + clinical:CoverageRecord) # ============================================================================ coverage:providerName a owl:DatatypeProperty ; rdfs:label "Provider Name"@en ; rdfs:comment "Name of insurance company or plan provider (e.g., Aetna, Blue Cross, Medicare). Unifies checkup:insuranceProvider and clinical:providerName."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:memberId a owl:DatatypeProperty ; rdfs:label "Member ID"@en ; rdfs:comment "Insurance policy member/subscriber ID number. Present in both patient-reported and EHR-imported data."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:groupNumber a owl:DatatypeProperty ; rdfs:label "Group Number"@en ; rdfs:comment "Employer group number for employer-sponsored plans. Present in both patient-reported and EHR-imported data."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:planName a owl:DatatypeProperty ; rdfs:label "Plan Name"@en ; rdfs:comment "Name of the insurance plan (e.g., 'Gold PPO 500'). Originally from clinical:CoverageRecord."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:planType a owl:DatatypeProperty ; rdfs:label "Plan Type"@en ; rdfs:comment "Type of insurance plan: hmo, ppo, epo, pos, hdhp, medicare, medicaid, tricare, other."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:coverageType a owl:DatatypeProperty ; rdfs:label "Coverage Type"@en ; rdfs:comment "Classification of coverage: primary, secondary, dental, vision."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:effectiveStart a owl:DatatypeProperty ; rdfs:label "Effective Start"@en ; rdfs:comment "Start date of coverage period. Maps to clinical:effectivePeriodStart and checkup:effectiveDate."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:date . coverage:effectiveEnd a owl:DatatypeProperty ; rdfs:label "Effective End"@en ; rdfs:comment "End date of coverage period. Maps to clinical:effectivePeriodEnd and checkup:expirationDate (for insurance usage)."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:date . coverage:subscriberId a owl:DatatypeProperty ; rdfs:label "Subscriber ID"@en ; rdfs:comment "Identifier for the policy holder from the insurer. From clinical:CoverageRecord."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . # ============================================================================ # Data Properties - Subscriber (from Intake Form, 2026-02-16) # ============================================================================ coverage:subscriberName a owl:DatatypeProperty ; rdfs:label "Subscriber Name"@en ; rdfs:comment "Name of insurance subscriber (the primary policyholder). From patient-reported intake form data."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:subscriberRelationship a owl:DatatypeProperty ; rdfs:label "Subscriber Relationship"@en ; rdfs:comment "Relationship of patient to subscriber: self, spouse, child, parent, other. Unifies clinical:relationship and checkup:subscriberRelationship with a typed enum constraint."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . # ============================================================================ # Data Properties - Pharmacy Benefits (from InsuranceInfo model) # ============================================================================ coverage:rxBin a owl:DatatypeProperty ; rdfs:label "Rx BIN"@en ; rdfs:comment "Pharmacy benefit BIN (Bank Identification Number). Used for prescription drug claims processing."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:rxPcn a owl:DatatypeProperty ; rdfs:label "Rx PCN"@en ; rdfs:comment "Pharmacy benefit PCN (Processor Control Number). Used for prescription drug claims routing."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . coverage:rxGroup a owl:DatatypeProperty ; rdfs:label "Rx Group"@en ; rdfs:comment "Pharmacy benefit group number. Identifies the patient's pharmacy benefit group for claims processing."@en ; rdfs:domain coverage:InsurancePlan ; rdfs:range xsd:string . # ============================================================================ # Alignment with Healthcare Standards # ============================================================================ # FHIR Coverage Resource Mapping # - coverage:InsurancePlan -> fhir:Coverage # - coverage:providerName -> fhir:Coverage.payor (display) # - coverage:memberId -> fhir:Coverage.identifier # - coverage:groupNumber -> fhir:Coverage.class (group) # - coverage:planName -> fhir:Coverage.class (plan) # - coverage:planType -> fhir:Coverage.type # - coverage:coverageType -> fhir:Coverage.class (category) # - coverage:effectiveStart -> fhir:Coverage.period.start # - coverage:effectiveEnd -> fhir:Coverage.period.end # - coverage:subscriberId -> fhir:Coverage.subscriberId # - coverage:subscriberRelationship -> fhir:Coverage.relationship # Future companion vocabulary: billing: (Layer 2) # - billing:Claim, billing:Bill, billing:Payment, billing:ExplanationOfBenefits # - Enables patient healthcare spending tracking and cost management # - Not in scope for this version # ============================================================================ # Changelog # ============================================================================ # # v1.3 (2026-03-17): Added coverage:deniedClinicalContext (ObjectProperty linking DenialNotice to clinical evidence in the Pod), # coverage:outcomeReason (free-text explanation of appeal outcome), coverage:reversalAmount (reimbursement if approved), # coverage:DenialReasonCode named individuals (standard-mapped enum values for denialReasonCode), # rdfs:seeAlso mappings to HL7 ClaimResponse.adjudication and CARIN IG adjudication codes. # # v1.2 (2026-03-16): Added coverage:DenialNotice class, coverage:AppealRecord class, and 11 new properties for denial/appeal workflow. # # Version 1.0 (2026-02-18) # - Initial release as part of Schema Refactoring Plan Phase 2 (WS4) # - Created to resolve overlap between checkup:InsuranceInfo (L3, patient-reported) # and clinical:CoverageRecord (L2, EHR-imported) # - InsurancePlan class with 14 properties: # - 8 core properties (providerName, memberId, groupNumber, planName, planType, # coverageType, effectiveStart, effectiveEnd) # - 3 subscriber properties (subscriberId, subscriberName, subscriberRelationship) # - 3 pharmacy benefit properties (rxBin, rxPcn, rxGroup) # - Deductible and CopaySchedule classes defined (properties deferred to future version) # - FHIR Coverage resource alignment documented # - Layer 2 domain vocabulary per three-layer architecture # - Recommended Pod storage: /coverage/plans/{plan-id}.ttl # # ============================================================================ # New Classes: ClaimRecord and BenefitStatement # Added in v1.1 — supports FHIR Claim and ExplanationOfBenefit conversion # ============================================================================ coverage:ClaimRecord a owl:Class ; rdfs:label "Claim Record"@en ; rdfs:comment "A medical claim submitted to an insurer for reimbursement. FHIR alignment: fhir:Claim"@en . coverage:BenefitStatement a owl:Class ; rdfs:label "Benefit Statement (EOB)"@en ; rdfs:comment "An Explanation of Benefits document — the insurer's formal response to a claim, including adjudication, denial reasons, and patient cost responsibility. FHIR alignment: fhir:ExplanationOfBenefit. CMS mandates patient access via CARIN Alliance FHIR IG."@en . coverage:DenialNotice a owl:Class ; rdfs:label "Denial Notice"@en ; rdfs:comment "A formal denial of coverage issued by an insurer. Distinct from BenefitStatement — a DenialNotice initiates an appeal process, not a payment record. Recommended Pod storage: /coverage/denials/{id}.ttl"@en ; rdfs:subClassOf prov:Entity ; rdfs:seeAlso fhir:ExplanationOfBenefit . coverage:AppealRecord a owl:Class ; rdfs:label "Appeal Record"@en ; rdfs:comment "A formal appeal filing contesting a denial notice. One record per appeal level. Recommended Pod storage: /coverage/appeals/{id}.ttl"@en ; rdfs:subClassOf prov:Activity ; rdfs:seeAlso fhir:Task . # ============================================================================ # New Properties: coverage:Deductible # ============================================================================ coverage:deductibleAmount a owl:DatatypeProperty ; rdfs:domain coverage:Deductible ; rdfs:range xsd:decimal ; rdfs:label "Deductible Amount"@en . coverage:deductibleCurrency a owl:DatatypeProperty ; rdfs:domain coverage:Deductible ; rdfs:range xsd:string ; rdfs:label "Deductible Currency"@en . coverage:deductibleMetAmount a owl:DatatypeProperty ; rdfs:domain coverage:Deductible ; rdfs:range xsd:decimal ; rdfs:label "Deductible Met Amount"@en . coverage:deductiblePeriod a owl:DatatypeProperty ; rdfs:domain coverage:Deductible ; rdfs:range xsd:string ; rdfs:label "Deductible Period"@en . coverage:deductibleType a owl:DatatypeProperty ; rdfs:domain coverage:Deductible ; rdfs:range xsd:string ; rdfs:label "Deductible Type"@en ; rdfs:comment "Values: individual, family, in-network, out-of-network"@en . # ============================================================================ # New Properties: coverage:CopaySchedule # ============================================================================ coverage:copayAmount a owl:DatatypeProperty ; rdfs:domain coverage:CopaySchedule ; rdfs:range xsd:decimal ; rdfs:label "Copay Amount"@en . coverage:copayCurrency a owl:DatatypeProperty ; rdfs:domain coverage:CopaySchedule ; rdfs:range xsd:string ; rdfs:label "Copay Currency"@en . coverage:copayType a owl:DatatypeProperty ; rdfs:domain coverage:CopaySchedule ; rdfs:range xsd:string ; rdfs:label "Copay Type"@en ; rdfs:comment "Values: primary-care, specialist, emergency, prescription"@en . # ============================================================================ # New Properties: coverage:ClaimRecord # ============================================================================ coverage:claimDate a owl:DatatypeProperty ; rdfs:domain coverage:ClaimRecord ; rdfs:range xsd:dateTime ; rdfs:label "Claim Date"@en . coverage:claimTotal a owl:DatatypeProperty ; rdfs:domain coverage:ClaimRecord ; rdfs:range xsd:decimal ; rdfs:label "Claim Total"@en . coverage:claimStatus a owl:DatatypeProperty ; rdfs:domain coverage:ClaimRecord ; rdfs:range xsd:string ; rdfs:label "Claim Status"@en ; rdfs:comment "Values: active, cancelled, draft, entered-in-error"@en . coverage:claimType a owl:DatatypeProperty ; rdfs:domain coverage:ClaimRecord ; rdfs:range xsd:string ; rdfs:label "Claim Type"@en ; rdfs:comment "Values: professional, institutional, oral, pharmacy, vision"@en . coverage:billingProvider a owl:DatatypeProperty ; rdfs:domain coverage:ClaimRecord ; rdfs:range xsd:string ; rdfs:label "Billing Provider"@en . coverage:hasDiagnosis a owl:DatatypeProperty ; rdfs:domain coverage:ClaimRecord ; rdfs:range xsd:string ; rdfs:label "Has Diagnosis"@en ; rdfs:comment "ICD-10 code URI"@en . coverage:hasProcedure a owl:DatatypeProperty ; rdfs:domain coverage:ClaimRecord ; rdfs:range xsd:string ; rdfs:label "Has Procedure"@en ; rdfs:comment "CPT/SNOMED code URI"@en . coverage:sourceRecordId a owl:DatatypeProperty ; rdfs:range xsd:string ; rdfs:label "Source Record ID"@en ; rdfs:comment "Original source system record identifier. No domain restriction — shared by ClaimRecord and BenefitStatement."@en . # ============================================================================ # New Properties: coverage:BenefitStatement # ============================================================================ coverage:adjudicationDate a owl:DatatypeProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range xsd:dateTime ; rdfs:label "Adjudication Date"@en . coverage:adjudicationStatus a owl:DatatypeProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range xsd:string ; rdfs:label "Adjudication Status"@en ; rdfs:comment "Values: completed, cancelled, entered-in-error"@en . coverage:outcomeCode a owl:DatatypeProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range xsd:string ; rdfs:label "Outcome Code"@en ; rdfs:comment "Values: queued, complete, error, partial"@en . coverage:denialReason a owl:DatatypeProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range xsd:string ; rdfs:label "Denial Reason"@en . coverage:totalBilled a owl:DatatypeProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range xsd:decimal ; rdfs:label "Total Billed"@en . coverage:totalAllowed a owl:DatatypeProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range xsd:decimal ; rdfs:label "Total Allowed"@en . coverage:totalPaid a owl:DatatypeProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range xsd:decimal ; rdfs:label "Total Paid"@en . coverage:patientResponsibility a owl:DatatypeProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range xsd:decimal ; rdfs:label "Patient Responsibility"@en . coverage:relatedClaim a owl:ObjectProperty ; rdfs:domain coverage:BenefitStatement ; rdfs:range coverage:ClaimRecord ; rdfs:label "Related Claim"@en ; rdfs:comment "Links an ExplanationOfBenefit to its corresponding Claim."@en . # ============================================================================ # v1.2 DenialNotice Properties # ============================================================================ coverage:deniedProcedureCode a owl:DatatypeProperty ; rdfs:label "Denied Procedure Code"@en ; rdfs:comment "CPT or HCPCS code of the denied service (e.g., E0787 for CGM)."@en ; rdfs:domain coverage:DenialNotice ; rdfs:range xsd:string . coverage:denialReasonCode a owl:DatatypeProperty ; rdfs:label "Denial Reason Code"@en ; rdfs:comment "Structured coded denial reason. Recommended values are coverage:DenialReasonCode named individuals (coverage:NotMedicallyNecessary, coverage:LCDCriteriaNotMet, coverage:NCDCriteriaNotMet, coverage:ServiceNotCovered, coverage:PriorAuthorizationRequired, coverage:DuplicateClaim, coverage:InformationRequested). Distinct from the free-text coverage:denialReason. Aligns with HL7 ClaimResponse adjudication and CARIN IG Blue Button STU2."@en ; rdfs:domain coverage:DenialNotice ; rdfs:range xsd:string ; rdfs:seeAlso , . coverage:denialLetterDate a owl:DatatypeProperty ; rdfs:label "Denial Letter Date"@en ; rdfs:comment "Date the denial notice was issued. The appeal deadline clock starts from this date."@en ; rdfs:domain coverage:DenialNotice ; rdfs:range xsd:date . coverage:appealDeadline a owl:DatatypeProperty ; rdfs:label "Appeal Deadline"@en ; rdfs:comment "Computed deadline for filing an appeal, based on the denial date, plan type, and applicable jurisdiction rules."@en ; rdfs:domain coverage:DenialNotice ; rdfs:range xsd:date . coverage:coveragePolicyReference a owl:DatatypeProperty ; rdfs:label "Coverage Policy Reference"@en ; rdfs:comment "The LCD, NCD, or coverage policy cited as the basis for denial (e.g., LCD L33822)."@en ; rdfs:domain coverage:DenialNotice ; rdfs:range xsd:string . # ============================================================================ # v1.2 AppealRecord Properties # ============================================================================ coverage:appealLevel a owl:DatatypeProperty ; rdfs:label "Appeal Level"@en ; rdfs:comment "The administrative level of this appeal. Values: redetermination, qio_reconsideration, alj_hearing, mac_review, federal_court, internal_level1, internal_level2, external_review, state_insurance_dept, litigation."@en ; rdfs:domain coverage:AppealRecord ; rdfs:range xsd:string . coverage:appealFiledDate a owl:DatatypeProperty ; rdfs:label "Appeal Filed Date"@en ; rdfs:comment "Date the appeal was formally filed."@en ; rdfs:domain coverage:AppealRecord ; rdfs:range xsd:date . coverage:appealOutcome a owl:DatatypeProperty ; rdfs:label "Appeal Outcome"@en ; rdfs:comment "Outcome of the appeal. Values: approved, denied, partial, withdrawn, pending."@en ; rdfs:domain coverage:AppealRecord ; rdfs:range xsd:string . coverage:appealOutcomeDate a owl:DatatypeProperty ; rdfs:label "Appeal Outcome Date"@en ; rdfs:comment "Date the appeal outcome was received."@en ; rdfs:domain coverage:AppealRecord ; rdfs:range xsd:date . coverage:relatedDenialNotice a owl:ObjectProperty ; rdfs:label "Related Denial Notice"@en ; rdfs:comment "Links an AppealRecord to the DenialNotice it contests."@en ; rdfs:domain coverage:AppealRecord ; rdfs:range coverage:DenialNotice . # ============================================================================ # v1.3 Properties # ============================================================================ coverage:deniedClinicalContext a owl:ObjectProperty ; rdfs:label "Denied Clinical Context"@en ; rdfs:comment "References clinical or health records in the Pod that are relevant to this denial — procedures, lab results, diagnoses, device readings. Enables appeals to cite specific clinical evidence against policy criteria. Range is intentionally open (rdfs:Resource) to allow linking across clinical:, health:, and pots: namespaces."@en ; rdfs:domain coverage:DenialNotice ; rdfs:range rdfs:Resource . coverage:outcomeReason a owl:DatatypeProperty ; rdfs:label "Outcome Reason"@en ; rdfs:comment "Free-text explanation of why the appeal was approved, denied, or partially approved. Captures the insurer's stated rationale for the outcome."@en ; rdfs:domain coverage:AppealRecord ; rdfs:range xsd:string . coverage:reversalAmount a owl:DatatypeProperty ; rdfs:label "Reversal Amount"@en ; rdfs:comment "Reimbursement amount granted if the appeal was approved or partially approved. Expressed as a decimal in the currency of the related InsurancePlan."@en ; rdfs:domain coverage:AppealRecord ; rdfs:range xsd:decimal . # ============================================================================ # v1.3 Named Individuals: DenialReasonCode # Standard-mapped enumeration values for coverage:denialReasonCode # Source mappings: # HL7 ClaimResponse.adjudication: http://terminology.hl7.org/CodeSystem/adjudication # CARIN IG for Blue Button: http://hl7.org/fhir/us/carin-bb/STU2/ # CMS Medicare denial codes: https://www.cms.gov/medicare/coding-billing/place-of-service-codes # ============================================================================ coverage:NotMedicallyNecessary a coverage:DenialReasonCode ; rdfs:label "Not Medically Necessary"@en ; rdfs:comment "Service denied as not meeting medical necessity criteria for the diagnosis. HL7 alignment: adjudication code 'noauth'. CMS reason: 50 (not medically necessary)."@en ; rdfs:seeAlso . coverage:LCDCriteriaNotMet a coverage:DenialReasonCode ; rdfs:label "LCD Criteria Not Met"@en ; rdfs:comment "Service denied because the patient does not meet the criteria in the applicable Local Coverage Determination (LCD). CMS LCD search: https://www.cms.gov/medicare-coverage-database/"@en ; rdfs:seeAlso . coverage:NCDCriteriaNotMet a coverage:DenialReasonCode ; rdfs:label "NCD Criteria Not Met"@en ; rdfs:comment "Service denied because the patient does not meet the criteria in the applicable National Coverage Determination (NCD)."@en ; rdfs:seeAlso . coverage:ServiceNotCovered a coverage:DenialReasonCode ; rdfs:label "Service Not Covered"@en ; rdfs:comment "The requested service is explicitly excluded from the patient's plan benefits. HL7 alignment: adjudication code 'benefit'."@en ; rdfs:seeAlso . coverage:PriorAuthorizationRequired a coverage:DenialReasonCode ; rdfs:label "Prior Authorization Required"@en ; rdfs:comment "The service requires prior authorization which was not obtained before service delivery. HL7 alignment: adjudication code 'noauth'. CARIN IG: X12 835 reason code 4."@en ; rdfs:seeAlso . coverage:DuplicateClaim a coverage:DenialReasonCode ; rdfs:label "Duplicate Claim"@en ; rdfs:comment "Claim denied as a duplicate of a previously processed claim. X12 835 reason code 18."@en . coverage:InformationRequested a coverage:DenialReasonCode ; rdfs:label "Additional Information Requested"@en ; rdfs:comment "Claim suspended or denied pending submission of additional clinical documentation. X12 835 reason code 16."@en . # DenialReasonCode type declaration (supports named individuals above) coverage:DenialReasonCode a owl:Class ; rdfs:label "Denial Reason Code"@en ; rdfs:comment "Enumeration class for structured denial reason codes. Use named individuals (coverage:NotMedicallyNecessary, etc.) as values for coverage:denialReasonCode. Aligns with HL7 ClaimResponse adjudication codes and CARIN IG for Blue Button (STU2)."@en ; rdfs:seeAlso , .