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
Financial Management Work Group | Maturity Level: 1 | Compartments: 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.
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
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
EligibilityRequest | DomainResource | Eligibility request | ||
identifier | 0..* | Identifier | Business Identifier | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error EligibilityRequestStatus (Required) |
ruleset | 0..1 | Coding | Resource version Ruleset Codes (Example) | |
originalRuleset | 0..1 | Coding | Original version Ruleset Codes (Example) | |
created | 0..1 | dateTime | Creation date | |
insurer[x] | 0..1 | Target | ||
insurerIdentifier | Identifier | |||
insurerReference | Reference(Organization) | |||
provider[x] | 0..1 | Responsible practitioner | ||
providerIdentifier | Identifier | |||
providerReference | Reference(Practitioner) | |||
organization[x] | 0..1 | Responsible organization | ||
organizationIdentifier | Identifier | |||
organizationReference | Reference(Organization) | |||
priority | 0..1 | Coding | Desired processing priority Priority Codes (Example) | |
enterer[x] | 0..1 | Author | ||
entererIdentifier | Identifier | |||
entererReference | Reference(Practitioner) | |||
facility[x] | 0..1 | Servicing Facility | ||
facilityIdentifier | Identifier | |||
facilityReference | Reference(Location) | |||
patient[x] | 0..1 | The subject of the Products and Services | ||
patientIdentifier | Identifier | |||
patientReference | Reference(Patient) | |||
coverage[x] | 0..1 | Insurance or medical plan | ||
coverageIdentifier | Identifier | |||
coverageReference | Reference(Coverage) | |||
businessArrangement | 0..1 | string | Business agreement | |
serviced[x] | 0..1 | Estimated date or dates of Service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
benefitCategory | 0..1 | Coding | Benefit Category Benefit Category Codes (Example) | |
benefitSubCategory | 0..1 | Coding | Benefit SubCategory Benefit SubCategory Codes (Example) | |
Documentation for this format |
UML Diagram (Legend)
XML Template
<EligibilityRequest 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 --> <ruleset><!-- 0..1 Coding Resource version --></ruleset> <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset> <created value="[dateTime]"/><!-- 0..1 Creation date --> <insurer[x]><!-- 0..1 Identifier|Reference(Organization) Target --></insurer[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
{ "resourceType" : "EligibilityRequest", // 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 "ruleset" : { Coding }, // Resource version "originalRuleset" : { Coding }, // Original version "created" : "<dateTime>", // Creation date // insurer[x]: Target. One of these 2: "insurerIdentifier" : { Identifier }, "insurerReference" : { 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 }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:EligibilityRequest; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:EligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier fhir:EligibilityRequest.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error fhir:EligibilityRequest.ruleset [ Coding ]; # 0..1 Resource version fhir:EligibilityRequest.originalRuleset [ Coding ]; # 0..1 Original version fhir:EligibilityRequest.created [ dateTime ]; # 0..1 Creation date # EligibilityRequest.insurer[x] : 0..1 Target. One of these 2 fhir:EligibilityRequest.insurerIdentifier [ Identifier ] fhir:EligibilityRequest.insurerReference [ Reference(Organization) ] # EligibilityRequest.provider[x] : 0..1 Responsible practitioner. One of these 2 fhir:EligibilityRequest.providerIdentifier [ Identifier ] fhir:EligibilityRequest.providerReference [ Reference(Practitioner) ] # EligibilityRequest.organization[x] : 0..1 Responsible organization. One of these 2 fhir:EligibilityRequest.organizationIdentifier [ Identifier ] fhir:EligibilityRequest.organizationReference [ Reference(Organization) ] fhir:EligibilityRequest.priority [ Coding ]; # 0..1 Desired processing priority # EligibilityRequest.enterer[x] : 0..1 Author. One of these 2 fhir:EligibilityRequest.entererIdentifier [ Identifier ] fhir:EligibilityRequest.entererReference [ Reference(Practitioner) ] # EligibilityRequest.facility[x] : 0..1 Servicing Facility. One of these 2 fhir:EligibilityRequest.facilityIdentifier [ Identifier ] fhir:EligibilityRequest.facilityReference [ Reference(Location) ] # EligibilityRequest.patient[x] : 0..1 The subject of the Products and Services. One of these 2 fhir:EligibilityRequest.patientIdentifier [ Identifier ] fhir:EligibilityRequest.patientReference [ Reference(Patient) ] # EligibilityRequest.coverage[x] : 0..1 Insurance or medical plan. One of these 2 fhir:EligibilityRequest.coverageIdentifier [ Identifier ] fhir:EligibilityRequest.coverageReference [ Reference(Coverage) ] fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement # EligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2 fhir:EligibilityRequest.servicedDate [ date ] fhir:EligibilityRequest.servicedPeriod [ Period ] fhir:EligibilityRequest.benefitCategory [ Coding ]; # 0..1 Benefit Category fhir:EligibilityRequest.benefitSubCategory [ Coding ]; # 0..1 Benefit SubCategory ]
Changes since DSTU2
EligibilityRequest | |
EligibilityRequest.status | added |
EligibilityRequest.insurer[x] | added |
EligibilityRequest.provider[x] |
Renamed from provider to provider[x] Add Identifier |
EligibilityRequest.organization[x] |
Renamed from organization to organization[x] Add Identifier |
EligibilityRequest.priority | added |
EligibilityRequest.enterer[x] | added |
EligibilityRequest.facility[x] | added |
EligibilityRequest.patient[x] | added |
EligibilityRequest.coverage[x] | added |
EligibilityRequest.businessArrangement | added |
EligibilityRequest.serviced[x] | added |
EligibilityRequest.benefitCategory | added |
EligibilityRequest.benefitSubCategory | added |
EligibilityRequest.target | deleted |
See the Full Difference for further information
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
EligibilityRequest | DomainResource | Eligibility request | ||
identifier | 0..* | Identifier | Business Identifier | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error EligibilityRequestStatus (Required) |
ruleset | 0..1 | Coding | Resource version Ruleset Codes (Example) | |
originalRuleset | 0..1 | Coding | Original version Ruleset Codes (Example) | |
created | 0..1 | dateTime | Creation date | |
insurer[x] | 0..1 | Target | ||
insurerIdentifier | Identifier | |||
insurerReference | Reference(Organization) | |||
provider[x] | 0..1 | Responsible practitioner | ||
providerIdentifier | Identifier | |||
providerReference | Reference(Practitioner) | |||
organization[x] | 0..1 | Responsible organization | ||
organizationIdentifier | Identifier | |||
organizationReference | Reference(Organization) | |||
priority | 0..1 | Coding | Desired processing priority Priority Codes (Example) | |
enterer[x] | 0..1 | Author | ||
entererIdentifier | Identifier | |||
entererReference | Reference(Practitioner) | |||
facility[x] | 0..1 | Servicing Facility | ||
facilityIdentifier | Identifier | |||
facilityReference | Reference(Location) | |||
patient[x] | 0..1 | The subject of the Products and Services | ||
patientIdentifier | Identifier | |||
patientReference | Reference(Patient) | |||
coverage[x] | 0..1 | Insurance or medical plan | ||
coverageIdentifier | Identifier | |||
coverageReference | Reference(Coverage) | |||
businessArrangement | 0..1 | string | Business agreement | |
serviced[x] | 0..1 | Estimated date or dates of Service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
benefitCategory | 0..1 | Coding | Benefit Category Benefit Category Codes (Example) | |
benefitSubCategory | 0..1 | Coding | Benefit SubCategory Benefit SubCategory Codes (Example) | |
Documentation for this format |
XML Template
<EligibilityRequest 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 --> <ruleset><!-- 0..1 Coding Resource version --></ruleset> <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset> <created value="[dateTime]"/><!-- 0..1 Creation date --> <insurer[x]><!-- 0..1 Identifier|Reference(Organization) Target --></insurer[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
{ "resourceType" : "EligibilityRequest", // 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 "ruleset" : { Coding }, // Resource version "originalRuleset" : { Coding }, // Original version "created" : "<dateTime>", // Creation date // insurer[x]: Target. One of these 2: "insurerIdentifier" : { Identifier }, "insurerReference" : { 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 }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:EligibilityRequest; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:EligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier fhir:EligibilityRequest.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error fhir:EligibilityRequest.ruleset [ Coding ]; # 0..1 Resource version fhir:EligibilityRequest.originalRuleset [ Coding ]; # 0..1 Original version fhir:EligibilityRequest.created [ dateTime ]; # 0..1 Creation date # EligibilityRequest.insurer[x] : 0..1 Target. One of these 2 fhir:EligibilityRequest.insurerIdentifier [ Identifier ] fhir:EligibilityRequest.insurerReference [ Reference(Organization) ] # EligibilityRequest.provider[x] : 0..1 Responsible practitioner. One of these 2 fhir:EligibilityRequest.providerIdentifier [ Identifier ] fhir:EligibilityRequest.providerReference [ Reference(Practitioner) ] # EligibilityRequest.organization[x] : 0..1 Responsible organization. One of these 2 fhir:EligibilityRequest.organizationIdentifier [ Identifier ] fhir:EligibilityRequest.organizationReference [ Reference(Organization) ] fhir:EligibilityRequest.priority [ Coding ]; # 0..1 Desired processing priority # EligibilityRequest.enterer[x] : 0..1 Author. One of these 2 fhir:EligibilityRequest.entererIdentifier [ Identifier ] fhir:EligibilityRequest.entererReference [ Reference(Practitioner) ] # EligibilityRequest.facility[x] : 0..1 Servicing Facility. One of these 2 fhir:EligibilityRequest.facilityIdentifier [ Identifier ] fhir:EligibilityRequest.facilityReference [ Reference(Location) ] # EligibilityRequest.patient[x] : 0..1 The subject of the Products and Services. One of these 2 fhir:EligibilityRequest.patientIdentifier [ Identifier ] fhir:EligibilityRequest.patientReference [ Reference(Patient) ] # EligibilityRequest.coverage[x] : 0..1 Insurance or medical plan. One of these 2 fhir:EligibilityRequest.coverageIdentifier [ Identifier ] fhir:EligibilityRequest.coverageReference [ Reference(Coverage) ] fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement # EligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2 fhir:EligibilityRequest.servicedDate [ date ] fhir:EligibilityRequest.servicedPeriod [ Period ] fhir:EligibilityRequest.benefitCategory [ Coding ]; # 0..1 Benefit Category fhir:EligibilityRequest.benefitSubCategory [ Coding ]; # 0..1 Benefit SubCategory ]
Changes since DSTU2
EligibilityRequest | |
EligibilityRequest.status | added |
EligibilityRequest.insurer[x] | added |
EligibilityRequest.provider[x] |
Renamed from provider to provider[x] Add Identifier |
EligibilityRequest.organization[x] |
Renamed from organization to organization[x] Add Identifier |
EligibilityRequest.priority | added |
EligibilityRequest.enterer[x] | added |
EligibilityRequest.facility[x] | added |
EligibilityRequest.patient[x] | added |
EligibilityRequest.coverage[x] | added |
EligibilityRequest.businessArrangement | added |
EligibilityRequest.serviced[x] | added |
EligibilityRequest.benefitCategory | added |
EligibilityRequest.benefitSubCategory | added |
EligibilityRequest.target | deleted |
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 |
---|---|---|---|
EligibilityRequest.status | A code specifying the state of the resource instance. | Required | EligibilityRequestStatus |
EligibilityRequest.ruleset EligibilityRequest.originalRuleset | The static and dynamic model to which contents conform, which may be business version or standard/version. | Example | Ruleset Codes |
EligibilityRequest.priority | The timeliness with which processing is required: STAT, normal, Deferred | Example | Priority Codes |
EligibilityRequest.benefitCategory | Benefit categories such as: oral, medical, vision etc. | Example | Benefit Category Codes |
EligibilityRequest.benefitSubCategory | Benefit subcategories such as: oral-basic, major, glasses | Example | Benefit SubCategory 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 for the EOB | EligibilityRequest.created |
facility-identifier | token | Facility responsible for the goods and services | EligibilityRequest.facilityidentifier |
facility-reference | reference | Facility responsible for the goods and services | EligibilityRequest.facilityReference (Location) |
identifier | token | The business identifier of the Eligibility | EligibilityRequest.identifier |
organization-identifier | token | The reference to the providing organization | EligibilityRequest.organizationidentifier |
organization-reference | reference | The reference to the providing organization | EligibilityRequest.organizationReference (Organization) |
patient-identifier | token | The reference to the patient | EligibilityRequest.patientIdentifier |
patient-reference | reference | The reference to the patient | EligibilityRequest.patientReference (Patient) |
provider-identifier | token | The reference to the provider | EligibilityRequest.provideridentifier |
provider-reference | reference | The reference to the provider | EligibilityRequest.providerReference (Practitioner) |