STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 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

7.4 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[x] Σ0..1Insurer
.... targetIdentifierIdentifier
.... targetReferenceReference(Organization)
... provider[x] Σ0..1Responsible practitioner
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] Σ0..1Responsible organization
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... enterer[x] Σ0..1Author
.... entererIdentifierIdentifier
.... entererReferenceReference(Practitioner)
... facility[x] Σ0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... patient[x] Σ0..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... coverage[x] Σ0..1Insurance or medical plan
.... coverageIdentifierIdentifier
.... coverageReferenceReference(Coverage)
... businessArrangement Σ0..1stringBusiness agreement
... 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[x] : Type [0..1] « Identifier|Reference(Organization) »The practitioner who is responsible for the services rendered to the patientprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The organization which is responsible for the services rendered to the patientorganization[x] : Type [0..1] « Identifier|Reference(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[x] : Type [0..1] « Identifier|Reference(Practitioner) »Facility where the services were providedfacility[x] : Type [0..1] « Identifier|Reference(Location) »Patient Resourcepatient[x] : Type [0..1] « Identifier|Reference(Patient) »Financial instrument by which payment information for health carecoverage[x] : Type [0..1] « Identifier|Reference(Coverage) »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]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[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></target[x]>
 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></organization[x]>
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <enterer[x]><!-- 0..1 Identifier|Reference(Practitioner) Author --></enterer[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <patient[x]><!-- 0..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>
 <coverage[x]><!-- 0..1 Identifier|Reference(Coverage) Insurance or medical plan --></coverage[x]>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <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>

JSON Template

{doco
  "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[x]: Insurer. One of these 2:
  "targetIdentifier" : { Identifier },
  "targetReference" : { Reference(Organization) },
  // provider[x]: Responsible practitioner. One of these 2:
  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization. One of these 2:
  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  "priority" : { Coding }, // Desired processing priority
  // enterer[x]: Author. One of these 2:
  "entererIdentifier" : { Identifier },
  "entererReference" : { Reference(Practitioner) },
  // facility[x]: Servicing Facility. One of these 2:
  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  // patient[x]: The subject of the Products and Services. One of these 2:
  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },
  // coverage[x]: Insurance or medical plan. One of these 2:
  "coverageIdentifier" : { Identifier },
  "coverageReference" : { Reference(Coverage) },
  "businessArrangement" : "<string>", // Business agreement
  // serviced[x]: Estimated date or dates of Service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "benefitCategory" : { Coding }, // Benefit Category
  "benefitSubCategory" : { Coding } // Benefit SubCategory
}

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[x] Σ0..1Insurer
.... targetIdentifierIdentifier
.... targetReferenceReference(Organization)
... provider[x] Σ0..1Responsible practitioner
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] Σ0..1Responsible organization
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... enterer[x] Σ0..1Author
.... entererIdentifierIdentifier
.... entererReferenceReference(Practitioner)
... facility[x] Σ0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... patient[x] Σ0..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... coverage[x] Σ0..1Insurance or medical plan
.... coverageIdentifierIdentifier
.... coverageReferenceReference(Coverage)
... businessArrangement Σ0..1stringBusiness agreement
... 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[x] : Type [0..1] « Identifier|Reference(Organization) »The practitioner who is responsible for the services rendered to the patientprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The organization which is responsible for the services rendered to the patientorganization[x] : Type [0..1] « Identifier|Reference(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[x] : Type [0..1] « Identifier|Reference(Practitioner) »Facility where the services were providedfacility[x] : Type [0..1] « Identifier|Reference(Location) »Patient Resourcepatient[x] : Type [0..1] « Identifier|Reference(Patient) »Financial instrument by which payment information for health carecoverage[x] : Type [0..1] « Identifier|Reference(Coverage) »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]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[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></target[x]>
 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></organization[x]>
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <enterer[x]><!-- 0..1 Identifier|Reference(Practitioner) Author --></enterer[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <patient[x]><!-- 0..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>
 <coverage[x]><!-- 0..1 Identifier|Reference(Coverage) Insurance or medical plan --></coverage[x]>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <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>

JSON Template

{doco
  "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[x]: Insurer. One of these 2:
  "targetIdentifier" : { Identifier },
  "targetReference" : { Reference(Organization) },
  // provider[x]: Responsible practitioner. One of these 2:
  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization. One of these 2:
  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  "priority" : { Coding }, // Desired processing priority
  // enterer[x]: Author. One of these 2:
  "entererIdentifier" : { Identifier },
  "entererReference" : { Reference(Practitioner) },
  // facility[x]: Servicing Facility. One of these 2:
  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  // patient[x]: The subject of the Products and Services. One of these 2:
  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },
  // coverage[x]: Insurance or medical plan. One of these 2:
  "coverageIdentifier" : { Identifier },
  "coverageReference" : { Reference(Coverage) },
  "businessArrangement" : "<string>", // Business agreement
  // serviced[x]: Estimated date or dates of Service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "benefitCategory" : { Coding }, // Benefit Category
  "benefitSubCategory" : { Coding } // Benefit SubCategory
}

 

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.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
facilityidentifiertokenFacility responsible for the goods and servicesEligibilityRequest.facilityidentifier
facilityreferencereferenceFacility responsible for the goods and servicesEligibilityRequest.facilityReference
(Location)
identifiertokenThe business identifier of the EligibilityEligibilityRequest.identifier
organizationidentifiertokenThe reference to the providing organizationEligibilityRequest.organizationidentifier
organizationreferencereferenceThe reference to the providing organizationEligibilityRequest.organizationReference
(Organization)
patientidentifiertokenThe reference to the patientEligibilityRequest.patientIdentifier
patientreferencereferenceThe reference to the patientEligibilityRequest.patientReference
(Patient)
provideridentifiertokenThe reference to the providerEligibilityRequest.provideridentifier
providerreferencereferenceThe reference to the providerEligibilityRequest.providerReference
(Practitioner)