STU 3 Ballot
FinancialThis page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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
| Financial Management Work Group | Maturity Level: 1 | Compartments: Not linked to any defined compartments |
This resource provides eligibility and plan details from the processing of an Eligibility resource.
The EligibilityResponse resource provides eligibility and plan details from the processing of an EligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy details.
Structure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  EligibilityResponse | DomainResource | EligibilityResponse resource | ||
  identifier | 0..* | Identifier | Business Identifier | |
 status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error EligibilityResponseStatus (Required) |
 request[x] | 0..1 | Claim reference | ||
 requestIdentifier | Identifier | |||
  requestReference | Reference(EligibilityRequest) | |||
| outcome | 0..1 | code | complete | error | partial RemittanceOutcome (Required) | |
| disposition | 0..1 | string | Disposition Message | |
| ruleset | 0..1 | Coding | Resource version Ruleset Codes (Example) | |
| originalRuleset | 0..1 | Coding | Original version Ruleset Codes (Example) | |
| created | 0..1 | dateTime | Creation date | |
| organization[x] | 0..1 | Insurer | ||
| organizationIdentifier | Identifier | |||
| organizationReference | Reference(Organization) | |||
| requestProvider[x] | 0..1 | Responsible practitioner | ||
| requestProviderIdentifier | Identifier | |||
| requestProviderReference | Reference(Practitioner) | |||
| requestOrganization[x] | 0..1 | Responsible organization | ||
| requestOrganizationIdentifier | Identifier | |||
| requestOrganizationReference | Reference(Organization) | |||
| inforce | 0..1 | boolean | Coverage inforce | |
| contract | 0..1 | Reference(Contract) | Contract details | |
| form | 0..1 | Coding | Printed Form Identifier Form Codes (Required) | |
 benefitBalance | 0..* | BackboneElement | Benefits by Category | |
| category | 1..1 | Coding | Benefit Category Benefit Category Codes (Example) | |
| subCategory | 0..1 | Coding | Benefit SubCategory Benefit SubCategory Codes (Example) | |
| name | 0..1 | string | Short name for the benefit | |
| description | 0..1 | string | Description of the benefit | |
| network | 0..1 | Coding | In or out of network Network Type Codes (Example) | |
| unit | 0..1 | Coding | Individual or family Unit Type Codes (Example) | |
| term | 0..1 | Coding | Annual or lifetime Benefit Term Codes (Example) | |
| financial | 0..* | BackboneElement | Benefit Summary | |
 type | 1..1 | Coding | Deductable, visits, benefit amount Benefit Type Codes (Example) | |
| benefit[x] | 0..1 | Benefits allowed | ||
| benefitUnsignedInt | unsignedInt | |||
| benefitString | string | |||
| benefitMoney | Money | |||
| benefitUsed[x] | 0..1 | Benefits used | ||
| benefitUsedUnsignedInt | unsignedInt | |||
| benefitUsedMoney | Money | |||
| error | 0..* | BackboneElement | Processing errors | |
| code | 1..1 | Coding | Error code detailing processing issues Adjudication Error Codes (Required) | |
| Documentation for this format | ||||
UML Diagram (Legend)
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> <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error --> <request[x]><!-- 0..1 Identifier|Reference(EligibilityRequest) Claim reference --></request[x]> <outcome value="[code]"/><!-- 0..1 complete | error | partial --> <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[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></organization[x]> <requestProvider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></requestProvider[x]> <requestOrganization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></requestOrganization[x]> <inforce value="[boolean]"/><!-- 0..1 Coverage inforce --> <contract><!-- 0..1 Reference(Contract) Contract details --></contract> <form><!-- 0..1 Coding Printed Form Identifier --></form> <benefitBalance> <!-- 0..* Benefits by Category --> <category><!-- 1..1 Coding Benefit Category --></category> <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory> <name value="[string]"/><!-- 0..1 Short name for the benefit --> <description value="[string]"/><!-- 0..1 Description of the benefit --> <network><!-- 0..1 Coding In or out of network --></network> <unit><!-- 0..1 Coding Individual or family --></unit> <term><!-- 0..1 Coding Annual or lifetime --></term> <financial> <!-- 0..* Benefit Summary --> <type><!-- 1..1 Coding Deductable, visits, benefit amount --></type> <benefit[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></benefit[x]> <benefitUsed[x]><!-- 0..1 unsignedInt|Money Benefits used --></benefitUsed[x]> </financial> </benefitBalance> <error> <!-- 0..* Processing errors --> <code><!-- 1..1 Coding Error code detailing processing issues --></code> </error> </EligibilityResponse>
JSON Template
{
"resourceType" : "EligibilityResponse",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // Business Identifier
"status" : "<code>", // R! active | cancelled | draft | entered-in-error
// request[x]: Claim reference. One of these 2:
"requestIdentifier" : { Identifier },
"requestReference" : { Reference(EligibilityRequest) },
"outcome" : "<code>", // complete | error | partial
"disposition" : "<string>", // Disposition Message
"ruleset" : { Coding }, // Resource version
"originalRuleset" : { Coding }, // Original version
"created" : "<dateTime>", // Creation date
// organization[x]: Insurer. One of these 2:
"organizationIdentifier" : { Identifier },
"organizationReference" : { Reference(Organization) },
// requestProvider[x]: Responsible practitioner. One of these 2:
"requestProviderIdentifier" : { Identifier },
"requestProviderReference" : { Reference(Practitioner) },
// requestOrganization[x]: Responsible organization. One of these 2:
"requestOrganizationIdentifier" : { Identifier },
"requestOrganizationReference" : { Reference(Organization) },
"inforce" : <boolean>, // Coverage inforce
"contract" : { Reference(Contract) }, // Contract details
"form" : { Coding }, // Printed Form Identifier
"benefitBalance" : [{ // Benefits by Category
"category" : { Coding }, // R! Benefit Category
"subCategory" : { Coding }, // Benefit SubCategory
"name" : "<string>", // Short name for the benefit
"description" : "<string>", // Description of the benefit
"network" : { Coding }, // In or out of network
"unit" : { Coding }, // Individual or family
"term" : { Coding }, // Annual or lifetime
"financial" : [{ // Benefit Summary
"type" : { Coding }, // R! Deductable, visits, benefit amount
// benefit[x]: Benefits allowed. One of these 3:
"benefitUnsignedInt" : "<unsignedInt>",
"benefitString" : "<string>",
"benefitMoney" : { Money },
// benefitUsed[x]: Benefits used. One of these 2:
"benefitUsedUnsignedInt" : "<unsignedInt>"
"benefitUsedMoney" : { Money }
}]
}],
"error" : [{ // Processing errors
"code" : { Coding } // R! Error code detailing processing issues
}]
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .
Changes since DSTU2
| EligibilityResponse | |
| EligibilityResponse.status | added |
| EligibilityResponse.request[x] |
Renamed from request to request[x] Add Identifier |
| EligibilityResponse.organization[x] |
Renamed from organization to organization[x] Add Identifier |
| EligibilityResponse.requestProvider[x] |
Renamed from requestProvider to requestProvider[x] Add Identifier |
| EligibilityResponse.requestOrganization[x] |
Renamed from requestOrganization to requestOrganization[x] Add Identifier |
| EligibilityResponse.inforce | added |
| EligibilityResponse.contract | added |
| EligibilityResponse.form | added |
| EligibilityResponse.benefitBalance | added |
| EligibilityResponse.benefitBalance.category | added |
| EligibilityResponse.benefitBalance.subCategory | added |
| EligibilityResponse.benefitBalance.name | added |
| EligibilityResponse.benefitBalance.description | added |
| EligibilityResponse.benefitBalance.network | added |
| EligibilityResponse.benefitBalance.unit | added |
| EligibilityResponse.benefitBalance.term | added |
| EligibilityResponse.benefitBalance.financial | added |
| EligibilityResponse.benefitBalance.financial.type | added |
| EligibilityResponse.benefitBalance.financial.benefit[x] | added |
| EligibilityResponse.benefitBalance.financial.benefitUsed[x] | added |
| EligibilityResponse.error | added |
| EligibilityResponse.error.code | added |
See the Full Difference for further information
Structure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| EligibilityResponse | DomainResource | EligibilityResponse resource | ||
| identifier | 0..* | Identifier | Business Identifier | |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error EligibilityResponseStatus (Required) |
| request[x] | 0..1 | Claim reference | ||
| requestIdentifier | Identifier | |||
| requestReference | Reference(EligibilityRequest) | |||
| outcome | 0..1 | code | complete | error | partial RemittanceOutcome (Required) | |
| disposition | 0..1 | string | Disposition Message | |
| ruleset | 0..1 | Coding | Resource version Ruleset Codes (Example) | |
| originalRuleset | 0..1 | Coding | Original version Ruleset Codes (Example) | |
| created | 0..1 | dateTime | Creation date | |
| organization[x] | 0..1 | Insurer | ||
| organizationIdentifier | Identifier | |||
| organizationReference | Reference(Organization) | |||
| requestProvider[x] | 0..1 | Responsible practitioner | ||
| requestProviderIdentifier | Identifier | |||
| requestProviderReference | Reference(Practitioner) | |||
| requestOrganization[x] | 0..1 | Responsible organization | ||
| requestOrganizationIdentifier | Identifier | |||
| requestOrganizationReference | Reference(Organization) | |||
| inforce | 0..1 | boolean | Coverage inforce | |
| contract | 0..1 | Reference(Contract) | Contract details | |
| form | 0..1 | Coding | Printed Form Identifier Form Codes (Required) | |
| benefitBalance | 0..* | BackboneElement | Benefits by Category | |
| category | 1..1 | Coding | Benefit Category Benefit Category Codes (Example) | |
| subCategory | 0..1 | Coding | Benefit SubCategory Benefit SubCategory Codes (Example) | |
| name | 0..1 | string | Short name for the benefit | |
| description | 0..1 | string | Description of the benefit | |
| network | 0..1 | Coding | In or out of network Network Type Codes (Example) | |
| unit | 0..1 | Coding | Individual or family Unit Type Codes (Example) | |
| term | 0..1 | Coding | Annual or lifetime Benefit Term Codes (Example) | |
| financial | 0..* | BackboneElement | Benefit Summary | |
| type | 1..1 | Coding | Deductable, visits, benefit amount Benefit Type Codes (Example) | |
| benefit[x] | 0..1 | Benefits allowed | ||
| benefitUnsignedInt | unsignedInt | |||
| benefitString | string | |||
| benefitMoney | Money | |||
| benefitUsed[x] | 0..1 | Benefits used | ||
| benefitUsedUnsignedInt | unsignedInt | |||
| benefitUsedMoney | Money | |||
| error | 0..* | BackboneElement | Processing errors | |
| code | 1..1 | Coding | Error code detailing processing issues Adjudication Error Codes (Required) | |
| Documentation for this format | ||||
XML Template
<EligibilityResponse xmlns="http://hl7.org/fhir">
JSON Template
{
"resourceType" : "EligibilityResponse",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // Business Identifier
"status" : "<code>", // R! active | cancelled | draft | entered-in-error
// request[x]: Claim reference. One of these 2:
"requestIdentifier" : { Identifier },
"requestReference" : { Reference(EligibilityRequest) },
"outcome" : "<code>", // complete | error | partial
"disposition" : "<string>", // Disposition Message
"ruleset" : { Coding }, // Resource version
"originalRuleset" : { Coding }, // Original version
"created" : "<dateTime>", // Creation date
// organization[x]: Insurer. One of these 2:
"organizationIdentifier" : { Identifier },
"organizationReference" : { Reference(Organization) },
// requestProvider[x]: Responsible practitioner. One of these 2:
"requestProviderIdentifier" : { Identifier },
"requestProviderReference" : { Reference(Practitioner) },
// requestOrganization[x]: Responsible organization. One of these 2:
"requestOrganizationIdentifier" : { Identifier },
"requestOrganizationReference" : { Reference(Organization) },
"inforce" : <boolean>, // Coverage inforce
"contract" : { Reference(Contract) }, // Contract details
"form" : { Coding }, // Printed Form Identifier
"benefitBalance" : [{ // Benefits by Category
"category" : { Coding }, // R! Benefit Category
"subCategory" : { Coding }, // Benefit SubCategory
"name" : "<string>", // Short name for the benefit
"description" : "<string>", // Description of the benefit
"network" : { Coding }, // In or out of network
"unit" : { Coding }, // Individual or family
"term" : { Coding }, // Annual or lifetime
"financial" : [{ // Benefit Summary
"type" : { Coding }, // R! Deductable, visits, benefit amount
// benefit[x]: Benefits allowed. One of these 3:
"benefitUnsignedInt" : "<unsignedInt>",
"benefitString" : "<string>",
"benefitMoney" : { Money },
// benefitUsed[x]: Benefits used. One of these 2:
"benefitUsedUnsignedInt" : "<unsignedInt>"
"benefitUsedMoney" : { Money }
}]
}],
"error" : [{ // Processing errors
"code" : { Coding } // R! Error code detailing processing issues
}]
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .
Changes since DSTU2
| EligibilityResponse | |
| EligibilityResponse.status | added |
| EligibilityResponse.request[x] |
Renamed from request to request[x] Add Identifier |
| EligibilityResponse.organization[x] |
Renamed from organization to organization[x] Add Identifier |
| EligibilityResponse.requestProvider[x] |
Renamed from requestProvider to requestProvider[x] Add Identifier |
| EligibilityResponse.requestOrganization[x] |
Renamed from requestOrganization to requestOrganization[x] Add Identifier |
| EligibilityResponse.inforce | added |
| EligibilityResponse.contract | added |
| EligibilityResponse.form | added |
| EligibilityResponse.benefitBalance | added |
| EligibilityResponse.benefitBalance.category | added |
| EligibilityResponse.benefitBalance.subCategory | added |
| EligibilityResponse.benefitBalance.name | added |
| EligibilityResponse.benefitBalance.description | added |
| EligibilityResponse.benefitBalance.network | added |
| EligibilityResponse.benefitBalance.unit | added |
| EligibilityResponse.benefitBalance.term | added |
| EligibilityResponse.benefitBalance.financial | added |
| EligibilityResponse.benefitBalance.financial.type | added |
| EligibilityResponse.benefitBalance.financial.benefit[x] | added |
| EligibilityResponse.benefitBalance.financial.benefitUsed[x] | added |
| EligibilityResponse.error | added |
| EligibilityResponse.error.code | added |
See the Full Difference for further information
Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle)
| Path | Definition | Type | Reference |
|---|---|---|---|
| EligibilityResponse.status | A code specifying the state of the resource instance. | Required | EligibilityResponseStatus |
| EligibilityResponse.outcome | The outcome of the processing. | Required | RemittanceOutcome |
| EligibilityResponse.ruleset EligibilityResponse.originalRuleset | The static and dynamic model to which contents conform, which may be business version or standard/version. | Example | Ruleset Codes |
| EligibilityResponse.form | The forms codes. | Required | Form Codes |
| EligibilityResponse.benefitBalance.category | Benefit categories such as: oral, medical, vision etc. | Example | Benefit Category Codes |
| EligibilityResponse.benefitBalance.subCategory | Benefit subcategories such as: oral-basic, major, glasses | Example | Benefit SubCategory Codes |
| EligibilityResponse.benefitBalance.network | Code to classify in or out of network services | Example | Network Type Codes |
| EligibilityResponse.benefitBalance.unit | Unit covered/serviced - individual or family | Example | Unit Type Codes |
| EligibilityResponse.benefitBalance.term | Coverage unit - annual, lifetime | Example | Benefit Term Codes |
| EligibilityResponse.benefitBalance.financial.type | Deductable, visits, co-pay, etc. | Example | Benefit Type Codes |
| EligibilityResponse.error.code | The error codes for adjudication processing. | Required | Adjudication Error Codes |
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 |
| created | date | The creation date | EligibilityResponse.created |
| disposition | string | The contents of the disposition message | EligibilityResponse.disposition |
| identifier | token | The business identifier | EligibilityResponse.identifier |
| organization-identifier | token | The organization which generated this resource | EligibilityResponse.organizationIdentifier |
| organization-reference | reference | The organization which generated this resource | EligibilityResponse.organizationReference (Organization) |
| outcome | token | The processing outcome | EligibilityResponse.outcome |
| request-identifier | token | The EligibilityRequest reference | EligibilityResponse.requestIdentifier |
| request-organization-identifier | token | The EligibilityRequest organization | EligibilityResponse.requestOrganizationIdentifier |
| request-organization-reference | reference | The EligibilityRequest organization | EligibilityResponse.requestOrganizationReference (Organization) |
| request-provider-identifier | token | The EligibilityRequest provider | EligibilityResponse.requestProviderIdentifier |
| request-provider-reference | reference | The EligibilityRequest provider | EligibilityResponse.requestProviderReference (Practitioner) |
| request-reference | reference | The EligibilityRequest reference | EligibilityResponse.requestReference (EligibilityRequest) |
© HL7.org 2011+. FHIR STU3 Ballot (v1.6.0-9663) generated on Thu, Aug 11, 2016 17:06+1000. QA Page
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