Connectathon 11 Snapshot

This page is part of the FHIR Specification (v1.2.0: STU 3 Draft). 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

7.4 Resource EligibilityRequest - Content

This resource is marked as a draft.

Financial Management Work GroupMaturity Level: 0Compartments: 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

7.4.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityRequest ΣDomainResourceEligibility request
... identifier Σ0..*IdentifierBusiness Identifier
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... target Σ0..1Reference(Organization)Insurer
... provider Σ0..1Reference(Practitioner)Responsible practitioner
... organization Σ0..1Reference(Organization)Responsible organization
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... enterer Σ0..1Reference(Practitioner)Author
... facility Σ0..1Reference(Location)Servicing Facility
... patient Σ0..1Reference(Patient)The subject of the Products and Services
... coverage Σ0..1Reference(Coverage)Insurance or medical plan
... businessArrangement Σ0..1stringBusiness agreement
... relationship Σ0..1CodingPatient relationship to subscriber
Surface Codes (Example)
... serviced[x] Σ0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... benefitCategory Σ0..1CodingBenefit Category
Benefit Category Codes (Example)
... benefitSubCategory Σ0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)

doco Documentation for this format

UML Diagram

EligibilityRequest (DomainResource)The Response business identifieridentifier : Identifier [0..*]The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when this resource was createdcreated : dateTime [0..1]The Insurer who is target of the requesttarget : Reference [0..1] « Organization »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientorganization : Reference [0..1] « Organization »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : Coding [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Priority ?? »Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner »Facility where the services were providedfacility : Reference [0..1] « Location »Patient Resourcepatient : Reference [0..1] « Patient »Financial instrument by which payment information for health carecoverage : Reference [0..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]The relationship of the patient to the subscriberrelationship : Coding [0..1] « The code for the relationship of the patient to the subscriber. (Strength=Example)Surface ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Dental, Vision, Medical, Pharmacy, Rehab etcbenefitCategory : Coding [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcbenefitSubCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »

XML Template

<EligibilityRequest xmlns="http://hl7.org/fhir"> doco
 <!-- 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>
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <relationship><!-- 0..1 Coding Patient relationship to subscriber --></relationship>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <benefitCategory><!-- 0..1 Coding Benefit Category --></benefitCategory>
 <benefitSubCategory><!-- 0..1 Coding Benefit SubCategory --></benefitSubCategory>
</EligibilityRequest>

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityRequest ΣDomainResourceEligibility request
... identifier Σ0..*IdentifierBusiness Identifier
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... target Σ0..1Reference(Organization)Insurer
... provider Σ0..1Reference(Practitioner)Responsible practitioner
... organization Σ0..1Reference(Organization)Responsible organization
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... enterer Σ0..1Reference(Practitioner)Author
... facility Σ0..1Reference(Location)Servicing Facility
... patient Σ0..1Reference(Patient)The subject of the Products and Services
... coverage Σ0..1Reference(Coverage)Insurance or medical plan
... businessArrangement Σ0..1stringBusiness agreement
... relationship Σ0..1CodingPatient relationship to subscriber
Surface Codes (Example)
... serviced[x] Σ0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... benefitCategory Σ0..1CodingBenefit Category
Benefit Category Codes (Example)
... benefitSubCategory Σ0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)

doco Documentation for this format

UML Diagram

EligibilityRequest (DomainResource)The Response business identifieridentifier : Identifier [0..*]The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when this resource was createdcreated : dateTime [0..1]The Insurer who is target of the requesttarget : Reference [0..1] « Organization »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientorganization : Reference [0..1] « Organization »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : Coding [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Priority ?? »Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner »Facility where the services were providedfacility : Reference [0..1] « Location »Patient Resourcepatient : Reference [0..1] « Patient »Financial instrument by which payment information for health carecoverage : Reference [0..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]The relationship of the patient to the subscriberrelationship : Coding [0..1] « The code for the relationship of the patient to the subscriber. (Strength=Example)Surface ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Dental, Vision, Medical, Pharmacy, Rehab etcbenefitCategory : Coding [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcbenefitSubCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »

XML Template

<EligibilityRequest xmlns="http://hl7.org/fhir"> doco
 <!-- 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>
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <relationship><!-- 0..1 Coding Patient relationship to subscriber --></relationship>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <benefitCategory><!-- 0..1 Coding Benefit Category --></benefitCategory>
 <benefitSubCategory><!-- 0..1 Coding Benefit SubCategory --></benefitSubCategory>
</EligibilityRequest>

 

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

7.4.2.1 Terminology Bindings

PathDefinitionTypeReference
EligibilityRequest.ruleset
EligibilityRequest.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version.ExampleRuleset Codes
EligibilityRequest.priority The timeliness with which processing is required: STAT, normal, DeferredExamplePriority Codes
EligibilityRequest.relationship The code for the relationship of the patient to the subscriber.ExampleSurface Codes
EligibilityRequest.benefitCategory Benefit categories such as: oral, medical, vision etc.ExampleBenefit Category Codes
EligibilityRequest.benefitSubCategory Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory 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.

NameTypeDescriptionPaths
createddateThe creation date for the EOBEligibilityRequest.created
facilityreferenceFacility responsible for the goods and servicesEligibilityRequest.facility
(Location)
identifiertokenThe business identifier of the EligibilityEligibilityRequest.identifier
organizationreferenceThe reference to the providing organizationEligibilityRequest.organization
(Organization)
patientreferenceThe reference to the patientEligibilityRequest.patient
(Patient)
providerreferenceThe reference to the providerEligibilityRequest.provider
(Practitioner)