STU 3 Ballot

This 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

13.4.5 Resource EligibilityRequest - Detailed Descriptions

Detailed Descriptions for the elements in the EligibilityRequest resource.

EligibilityRequest
Definition

This resource provides the insurance eligibility details from the insurer regarding a specified coverage and optionally some class of service.

Control1..1
EligibilityRequest.identifier
Definition

The Response business identifier.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
EligibilityRequest.status
Definition

The status of the resource instance.

Control1..1
BindingEligibilityRequestStatus: A code specifying the state of the resource instance. (Required)
Typecode
Is Modifiertrue
Summarytrue
EligibilityRequest.ruleset
Definition

The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources.

Control0..1
BindingRuleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. (Example)
TypeCoding
EligibilityRequest.originalRuleset
Definition

The style (standard) and version of the original material which was converted into this resource.

Control0..1
BindingRuleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. (Example)
TypeCoding
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.

EligibilityRequest.created
Definition

The date when this resource was created.

Control0..1
TypedateTime
EligibilityRequest.insurer[x]
Definition

The Insurer who is target of the request.

Control0..1
TypeIdentifier|Reference(Organization)
[x] NoteSee Choice of Data Types for further information about how to use [x]
EligibilityRequest.provider[x]
Definition

The practitioner who is responsible for the services rendered to the patient.

Control0..1
TypeIdentifier|Reference(Practitioner)
[x] NoteSee Choice of Data Types for further information about how to use [x]
EligibilityRequest.organization[x]
Definition

The organization which is responsible for the services rendered to the patient.

Control0..1
TypeIdentifier|Reference(Organization)
[x] NoteSee Choice of Data Types for further information about how to use [x]
EligibilityRequest.priority
Definition

Immediate (STAT), best effort (NORMAL), deferred (DEFER).

Control0..1
BindingPriority Codes: The timeliness with which processing is required: STAT, normal, Deferred (Example)
TypeCoding
EligibilityRequest.enterer[x]
Definition

Person who created the invoice/claim/pre-determination or pre-authorization.

Control0..1
TypeIdentifier|Reference(Practitioner)
[x] NoteSee Choice of Data Types for further information about how to use [x]
EligibilityRequest.facility[x]
Definition

Facility where the services were provided.

Control0..1
TypeIdentifier|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
EligibilityRequest.patient[x]
Definition

Patient Resource.

Control0..1
TypeIdentifier|Reference(Patient)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Comments

1..1.

EligibilityRequest.coverage[x]
Definition

Financial instrument by which payment information for health care.

Control0..1
TypeIdentifier|Reference(Coverage)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

Comments

1..1.

EligibilityRequest.businessArrangement
Definition

The contract number of a business agreement which describes the terms and conditions.

Control0..1
Typestring
EligibilityRequest.serviced[x]
Definition

The date or dates when the enclosed suite of services were performed or completed.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
EligibilityRequest.benefitCategory
Definition

Dental, Vision, Medical, Pharmacy, Rehab etc.

Control0..1
BindingBenefit Category Codes: Benefit categories such as: oral, medical, vision etc. (Example)
TypeCoding
EligibilityRequest.benefitSubCategory
Definition

Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.

Control0..1
BindingBenefit SubCategory Codes: Benefit subcategories such as: oral-basic, major, glasses (Example)
TypeCoding