DSTU2 QA Preview

This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). 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

7.5 Resource EligibilityResponse - 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 eligibility and plan details from the processing of an Eligibility resource.

7.5.1 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 EligibilityResponse resource provides eligibility and plan details from the processing of an Eligibility resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy details.

Todo

Structure

Name	Flags	Card.	Type	Description & Constraints
EligibilityResponse	Σ		DomainResource	EligibilityResponse resource
identifier	Σ	0..*	Identifier	Business Identifier
request	Σ	0..1	Reference(EligibilityRequest)	Claim reference
outcome	Σ	0..1	code	complete \| error RemittanceOutcome (Required)
disposition	Σ	0..1	string	Disposition Message
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
organization	Σ	0..1	Reference(Organization)	Insurer
requestProvider	Σ	0..1	Reference(Practitioner)	Responsible practitioner
requestOrganization	Σ	0..1	Reference(Organization)	Responsible organization
Documentation for this format

UML Diagram

XML Template

<EligibilityResponse 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>
 <request><!-- 0..1 Reference(EligibilityRequest) Claim reference --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
</EligibilityResponse>

JSON Template

{
  "resourceType" : "EligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "request" : { Reference(EligibilityRequest) }, // Claim reference
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) } // Responsible organization
}

Structure

Name	Flags	Card.	Type	Description & Constraints
EligibilityResponse	Σ		DomainResource	EligibilityResponse resource
identifier	Σ	0..*	Identifier	Business Identifier
request	Σ	0..1	Reference(EligibilityRequest)	Claim reference
outcome	Σ	0..1	code	complete \| error RemittanceOutcome (Required)
disposition	Σ	0..1	string	Disposition Message
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
organization	Σ	0..1	Reference(Organization)	Insurer
requestProvider	Σ	0..1	Reference(Practitioner)	Responsible practitioner
requestOrganization	Σ	0..1	Reference(Organization)	Responsible organization
Documentation for this format

UML Diagram

XML Template

<EligibilityResponse 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>
 <request><!-- 0..1 Reference(EligibilityRequest) Claim reference --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
</EligibilityResponse>

JSON Template

{
  "resourceType" : "EligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "request" : { Reference(EligibilityRequest) }, // Claim reference
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) } // Responsible organization
}

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

7.5.2.1 Terminology Bindings

Path	Definition	Type	Reference
EligibilityResponse.outcome	The outcome of the processing.	Required	RemittanceOutcome
EligibilityResponse.ruleset EligibilityResponse.originalRuleset	The static and dynamic model to which contents conform, may be business version or standard and version.	Example	Ruleset Codes

Path

Definition

Type

Reference

EligibilityResponse.outcome

The outcome of the processing.

Required

RemittanceOutcome

EligibilityResponse.ruleset
EligibilityResponse.originalRuleset

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

Example

Ruleset Codes

7.5.3 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 Explanation of Benefit	EligibilityResponse.identifier