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 Resource EligibilityResponse - Content

This resource is marked as a draft.

Financial Management Work GroupMaturity Level: 0Compartments: 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

7.5.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityResponse ΣDomainResourceEligibilityResponse resource
... identifier Σ0..*IdentifierBusiness Identifier
... request[x] Σ0..1Claim reference
.... requestIdentifierIdentifier
.... requestReferenceReference(EligibilityRequest)
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... organization[x] Σ0..1Insurer
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... requestProvider[x] Σ0..1Responsible practitioner
.... requestProviderIdentifierIdentifier
.... requestProviderReferenceReference(Practitioner)
... requestOrganization[x] Σ0..1Responsible organization
.... requestOrganizationIdentifierIdentifier
.... requestOrganizationReferenceReference(Organization)
... inforce Σ0..1booleanCoverage inforce
... contract Σ0..1Reference(Contract)Contract details
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... benefitBalance Σ0..*BackboneElementBenefits by Category
.... category Σ1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory Σ0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... network Σ0..1CodingIn or out of network
Network Type Codes (Example)
.... unit Σ0..1CodingIndividual or family
Unit Type Codes (Example)
.... term Σ0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial Σ0..*BackboneElementBenefit Summary
..... type Σ1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] Σ0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitQuantityMoney
..... benefitUsed[x] Σ0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedQuantityMoney
... error Σ0..*BackboneElementProcessing errors
.... code Σ1..1CodingError code detailing processing issues
Adjudication Error Codes (Required)

doco Documentation for this format

UML Diagram

EligibilityResponse (DomainResource)The Response business identifieridentifier : Identifier [0..*]Original request resource referencerequest[x] : Type [0..1] « Identifier|Reference(EligibilityRequest) »Transaction status: error, completeoutcome : code [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]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 the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseorganization[x] : Type [0..1] « Identifier|Reference(Organization) »The practitioner who is responsible for the services rendered to the patientrequestProvider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The organization which is responsible for the services rendered to the patientrequestOrganization[x] : Type [0..1] « Identifier|Reference( Organization) »Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service datesinforce : boolean [0..1]The contract resource which may provide more detailed informationcontract : Reference [0..1] « Contract »The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »BenefitsDental, Vision, Medical, Pharmacy, Rehab etccategory : Coding [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcsubCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »Network designationnetwork : Coding [0..1] « Code to classify in or out of network services (Strength=Example)Network Type ?? »Unit designation: individual or familyunit : Coding [0..1] « Unit covered/serviced - individual or family (Strength=Example)Unit Type ?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'term : Coding [0..1] « Coverage unit - annual, lifetime (Strength=Example)Benefit Term ?? »BenefitDeductable, visits, benefit amounttype : Coding [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)Benefit Type ?? »Benefits allowedbenefit[x] : Type [0..1] « unsignedInt|Quantity(Money) »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|Quantity(Money) »ErrorsAn error code,from a specified code system, which details why the eligibility check could not be performedcode : Coding [1..1] « The error codes for adjudication processing. (Strength=Required)Adjudication Error ! »Benefits Used to datefinancial[0..*]Benefits and optionally current balances by CategorybenefitBalance[0..*]

XML Template

<EligibilityResponse 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>
 <request[x]><!-- 0..1 Identifier|Reference(EligibilityRequest) Claim reference --></request[x]>
 <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[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>
  <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|Quantity(Money) Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Quantity(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

{doco
  "resourceType" : "EligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  // request[x]: Claim reference. One of these 2:
  "requestIdentifier" : { Identifier },
  "requestReference" : { Reference(EligibilityRequest) },
  "outcome" : "<code>", // complete | error
  "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
    "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 2:
      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitQuantity" : { Quantity(Money) },
      // benefitUsed[x]: Benefits used. One of these 2:
      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedQuantity" : { Quantity(Money) }
    }]
  }],
  "error" : [{ // Processing errors
    "code" : { Coding } // R!  Error code detailing processing issues
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityResponse ΣDomainResourceEligibilityResponse resource
... identifier Σ0..*IdentifierBusiness Identifier
... request[x] Σ0..1Claim reference
.... requestIdentifierIdentifier
.... requestReferenceReference(EligibilityRequest)
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... organization[x] Σ0..1Insurer
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... requestProvider[x] Σ0..1Responsible practitioner
.... requestProviderIdentifierIdentifier
.... requestProviderReferenceReference(Practitioner)
... requestOrganization[x] Σ0..1Responsible organization
.... requestOrganizationIdentifierIdentifier
.... requestOrganizationReferenceReference(Organization)
... inforce Σ0..1booleanCoverage inforce
... contract Σ0..1Reference(Contract)Contract details
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... benefitBalance Σ0..*BackboneElementBenefits by Category
.... category Σ1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory Σ0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... network Σ0..1CodingIn or out of network
Network Type Codes (Example)
.... unit Σ0..1CodingIndividual or family
Unit Type Codes (Example)
.... term Σ0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial Σ0..*BackboneElementBenefit Summary
..... type Σ1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] Σ0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitQuantityMoney
..... benefitUsed[x] Σ0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedQuantityMoney
... error Σ0..*BackboneElementProcessing errors
.... code Σ1..1CodingError code detailing processing issues
Adjudication Error Codes (Required)

doco Documentation for this format

UML Diagram

EligibilityResponse (DomainResource)The Response business identifieridentifier : Identifier [0..*]Original request resource referencerequest[x] : Type [0..1] « Identifier|Reference(EligibilityRequest) »Transaction status: error, completeoutcome : code [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]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 the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseorganization[x] : Type [0..1] « Identifier|Reference(Organization) »The practitioner who is responsible for the services rendered to the patientrequestProvider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The organization which is responsible for the services rendered to the patientrequestOrganization[x] : Type [0..1] « Identifier|Reference( Organization) »Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service datesinforce : boolean [0..1]The contract resource which may provide more detailed informationcontract : Reference [0..1] « Contract »The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »BenefitsDental, Vision, Medical, Pharmacy, Rehab etccategory : Coding [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcsubCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »Network designationnetwork : Coding [0..1] « Code to classify in or out of network services (Strength=Example)Network Type ?? »Unit designation: individual or familyunit : Coding [0..1] « Unit covered/serviced - individual or family (Strength=Example)Unit Type ?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'term : Coding [0..1] « Coverage unit - annual, lifetime (Strength=Example)Benefit Term ?? »BenefitDeductable, visits, benefit amounttype : Coding [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)Benefit Type ?? »Benefits allowedbenefit[x] : Type [0..1] « unsignedInt|Quantity(Money) »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|Quantity(Money) »ErrorsAn error code,from a specified code system, which details why the eligibility check could not be performedcode : Coding [1..1] « The error codes for adjudication processing. (Strength=Required)Adjudication Error ! »Benefits Used to datefinancial[0..*]Benefits and optionally current balances by CategorybenefitBalance[0..*]

XML Template

<EligibilityResponse 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>
 <request[x]><!-- 0..1 Identifier|Reference(EligibilityRequest) Claim reference --></request[x]>
 <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[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>
  <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|Quantity(Money) Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Quantity(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

{doco
  "resourceType" : "EligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  // request[x]: Claim reference. One of these 2:
  "requestIdentifier" : { Identifier },
  "requestReference" : { Reference(EligibilityRequest) },
  "outcome" : "<code>", // complete | error
  "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
    "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 2:
      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitQuantity" : { Quantity(Money) },
      // benefitUsed[x]: Benefits used. One of these 2:
      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedQuantity" : { Quantity(Money) }
    }]
  }],
  "error" : [{ // Processing errors
    "code" : { Coding } // R!  Error code detailing processing issues
  }]
}

 

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

7.5.2.1 Terminology Bindings

PathDefinitionTypeReference
EligibilityResponse.outcome The outcome of the processing.RequiredRemittanceOutcome
EligibilityResponse.ruleset
EligibilityResponse.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version.ExampleRuleset Codes
EligibilityResponse.form The forms codes.RequiredForm Codes
EligibilityResponse.benefitBalance.category Benefit categories such as: oral, medical, vision etc.ExampleBenefit Category Codes
EligibilityResponse.benefitBalance.subCategory Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory Codes
EligibilityResponse.benefitBalance.network Code to classify in or out of network servicesExampleNetwork Type Codes
EligibilityResponse.benefitBalance.unit Unit covered/serviced - individual or familyExampleUnit Type Codes
EligibilityResponse.benefitBalance.term Coverage unit - annual, lifetimeExampleBenefit Term Codes
EligibilityResponse.benefitBalance.financial.type Deductable, visits, co-pay, etc.ExampleBenefit Type Codes
EligibilityResponse.error.code The error codes for adjudication processing.RequiredAdjudication Error 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.

NameTypeDescriptionPaths
createddateThe creation dateEligibilityResponse.created
dispositionstringThe contents of the disposition messageEligibilityResponse.disposition
identifiertokenThe business identifierEligibilityResponse.identifier
organizationidentifiertokenThe organization which generated this resourceEligibilityResponse.organizationIdentifier
organizationreferencereferenceThe organization which generated this resourceEligibilityResponse.organizationReference
(Organization)
outcometokenThe processing outcomeEligibilityResponse.outcome
requestidentifiertokenThe EligibilityRequest referenceEligibilityResponse.requestIdentifier
requestorganizationidentifiertokenThe EligibilityRequest organizationEligibilityResponse.requestOrganizationIdentifier
requestorganizationreferencereferenceThe EligibilityRequest organizationEligibilityResponse.requestOrganizationReference
(Organization)
requestprovideridentifiertokenThe EligibilityRequest providerEligibilityResponse.requestProviderIdentifier
requestproviderreferencereferenceThe EligibilityRequest providerEligibilityResponse.requestProviderReference
(Practitioner)
requestreferencereferenceThe EligibilityRequest referenceEligibilityResponse.requestReference
(EligibilityRequest)