GAO Ballot Package

This page is part of the FHIR Specification (v1.1.0: STU 3 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R3 R2

This is a frozen snapshot of the FHIR specification created for the purpose of balloting the GAO implementation Guide. It includes draft changes that may be part of the future DSTU 2.1 release but further change is expected. Readers should focus solely on the GAO implementation content, and FHIR DSTU 2 for other purposes.

7.4 Resource EligibilityRequest - Content

This resource is marked as a draft.

Financial Management

Work Group

Maturity Level: 0

Compartments: Not linked to any defined compartments

This resource provides the insurance eligibility details from the insurer regarding a specified coverage and optionally some class of service.

7.4.1 Scope and Usage

This resource has not yet undergone proper review by FM. At this time, it is to be considered as a draft.

The EligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an Eligibility Response, with information regarding whether the stated coverage is valid and in-force, and potentially the amount of coverage which may be available to any services classes identified in this request. Todo

This resource is referenced by eligibilityresponse

Structure

Name	Flags	Card.	Type	Description & Constraints
EligibilityRequest	Σ		DomainResource	Eligibility request
identifier	Σ	0..*	Identifier	Business Identifier
ruleset	Σ	0..1	Coding	Resource version Ruleset Codes (Example)
originalRuleset	Σ	0..1	Coding	Original version Ruleset Codes (Example)
created	Σ	0..1	dateTime	Creation date
target	Σ	0..1	Reference(Organization)	Insurer
provider	Σ	0..1	Reference(Practitioner)	Responsible practitioner
organization	Σ	0..1	Reference(Organization)	Responsible organization
Documentation for this format

UML Diagram

XML Template

<EligibilityRequest xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <target><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
</EligibilityRequest>

JSON Template

{
  "resourceType" : "EligibilityRequest",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible practitioner
  "organization" : { Reference(Organization) } // Responsible organization
}

Structure

Name	Flags	Card.	Type	Description & Constraints
EligibilityRequest	Σ		DomainResource	Eligibility request
identifier	Σ	0..*	Identifier	Business Identifier
ruleset	Σ	0..1	Coding	Resource version Ruleset Codes (Example)
originalRuleset	Σ	0..1	Coding	Original version Ruleset Codes (Example)
created	Σ	0..1	dateTime	Creation date
target	Σ	0..1	Reference(Organization)	Insurer
provider	Σ	0..1	Reference(Practitioner)	Responsible practitioner
organization	Σ	0..1	Reference(Organization)	Responsible organization
Documentation for this format

UML Diagram

XML Template

<EligibilityRequest xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <target><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
</EligibilityRequest>

JSON Template

{
  "resourceType" : "EligibilityRequest",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible practitioner
  "organization" : { Reference(Organization) } // Responsible organization
}

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.4.2.1 Terminology Bindings

Path	Definition	Type	Reference
EligibilityRequest.ruleset EligibilityRequest.originalRuleset	The static and dynamic model to which contents conform, which may be business version or standard/version.	Example	Ruleset Codes

Path

Definition

Type

Reference

EligibilityRequest.ruleset
EligibilityRequest.originalRuleset

The static and dynamic model to which contents conform, which may be business version or standard/version.

Example

Ruleset Codes

7.4.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name	Type	Description	Paths
identifier	token	The business identifier of the Eligibility	EligibilityRequest.identifier