EligibilityResponse - FHIR v1.4.0

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

7.5.5 Resource EligibilityResponse - Detailed Descriptions

Detailed Descriptions for the elements in the EligibilityResponse resource.

EligibilityResponse
Definition	This resource provides eligibility and plan details from the processing of an Eligibility resource.
Control	1..1
Summary	true
EligibilityResponse.identifier
Definition	The Response business identifier.
Note	This is a business identifer, not a resource identifier (see discussion)
Control	0..*
Type	Identifier
Summary	true
EligibilityResponse.request[x]
Definition	Original request resource reference.
Control	0..1
Type	Identifier\|Reference(EligibilityRequest)
[x] Note	See Choice of Data Types for further information about how to use [x]
Summary	true
EligibilityResponse.outcome
Definition	Transaction status: error, complete.
Control	0..1
Binding	RemittanceOutcome: The outcome of the processing. (Required)
Type	code
Summary	true
EligibilityResponse.disposition
Definition	A description of the status of the adjudication.
Control	0..1
Type	string
Summary	true
EligibilityResponse.ruleset
Definition	The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources.
Control	0..1
Binding	Ruleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. (Example)
Type	Coding
Summary	true
EligibilityResponse.originalRuleset
Definition	The style (standard) and version of the original material which was converted into this resource.
Control	0..1
Binding	Ruleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. (Example)
Type	Coding
Requirements	Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.
Summary	true
EligibilityResponse.created
Definition	The date when the enclosed suite of services were performed or completed.
Control	0..1
Type	dateTime
Summary	true
EligibilityResponse.organization[x]
Definition	The Insurer who produced this adjudicated response.
Control	0..1
Type	Identifier\|Reference(Organization)
[x] Note	See Choice of Data Types for further information about how to use [x]
Summary	true
EligibilityResponse.requestProvider[x]
Definition	The practitioner who is responsible for the services rendered to the patient.
Control	0..1
Type	Identifier\|Reference(Practitioner)
[x] Note	See Choice of Data Types for further information about how to use [x]
Summary	true
EligibilityResponse.requestOrganization[x]
Definition	The organization which is responsible for the services rendered to the patient.
Control	0..1
Type	Identifier\|Reference(Organization)
[x] Note	See Choice of Data Types for further information about how to use [x]
Summary	true
EligibilityResponse.inforce
Definition	Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.
Control	0..1
Type	boolean
Summary	true
EligibilityResponse.contract
Definition	The contract resource which may provide more detailed information.
Control	0..1
Type	Reference(Contract)
Summary	true
EligibilityResponse.form
Definition	The form to be used for printing the content.
Control	0..1
Binding	Form Codes: The forms codes. (Required)
Type	Coding
Summary	true
EligibilityResponse.benefitBalance
Definition	Benefits and optionally current balances by Category.
Control	0..*
Summary	true
EligibilityResponse.benefitBalance.category
Definition	Dental, Vision, Medical, Pharmacy, Rehab etc.
Control	1..1
Binding	Benefit Category Codes: Benefit categories such as: oral, medical, vision etc. (Example)
Type	Coding
Summary	true
EligibilityResponse.benefitBalance.subCategory
Definition	Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.
Control	0..1
Binding	Benefit SubCategory Codes: Benefit subcategories such as: oral-basic, major, glasses (Example)
Type	Coding
Summary	true
EligibilityResponse.benefitBalance.network
Definition	Network designation.
Control	0..1
Binding	Network Type Codes: Code to classify in or out of network services (Example)
Type	Coding
Summary	true
EligibilityResponse.benefitBalance.unit
Definition	Unit designation: individual or family.
Control	0..1
Binding	Unit Type Codes: Unit covered/serviced - individual or family (Example)
Type	Coding
Summary	true
EligibilityResponse.benefitBalance.term
Definition	The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.
Control	0..1
Binding	Benefit Term Codes: Coverage unit - annual, lifetime (Example)
Type	Coding
Summary	true
EligibilityResponse.benefitBalance.financial
Definition	Benefits Used to date.
Control	0..*
Summary	true
EligibilityResponse.benefitBalance.financial.type
Definition	Deductable, visits, benefit amount.
Control	1..1
Binding	Benefit Type Codes: Deductable, visits, co-pay, etc. (Example)
Type	Coding
Summary	true
EligibilityResponse.benefitBalance.financial.benefit[x]
Definition	Benefits allowed.
Control	0..1
Type	unsignedInt\|Money
[x] Note	See Choice of Data Types for further information about how to use [x]
Summary	true
EligibilityResponse.benefitBalance.financial.benefitUsed[x]
Definition	Benefits used.
Control	0..1
Type	unsignedInt\|Money
[x] Note	See Choice of Data Types for further information about how to use [x]
Summary	true
EligibilityResponse.error
Definition	Mutually exclusive with Services Provided (Item).
Control	0..*
Summary	true
EligibilityResponse.error.code
Definition	An error code,from a specified code system, which details why the eligibility check could not be performed.
Control	1..1
Binding	Adjudication Error Codes: The error codes for adjudication processing. (Required)
Type	Coding
Summary	true