STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). 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 Resource EligibilityRequest - Content

Financial Management Work GroupMaturity Level: 1Compartments: Not linked to any defined compartments

This resource provides the details from the insurer to identify a specified coverage and optionally some class of service.

13.4.1 Scope and Usage

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

13.4.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityRequest DomainResourceEligibility request
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... priority 0..1CodeableConceptDesired processing priority
Priority Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... provider 0..1Reference(Practitioner)Responsible practitioner
... organization 0..1Reference(Organization)Responsible organization
... insurer 0..1Reference(Organization)Target
... facility 0..1Reference(Location)Servicing Facility
... coverage 0..1Reference(Coverage)Insurance or medical plan
... businessArrangement 0..1stringBusiness agreement
... benefitCategory 0..1CodeableConceptBenefit Category
Benefit Category Codes (Example)
... benefitSubCategory 0..1CodeableConceptBenefit SubCategory
Benefit SubCategory Codes (Example)

doco Documentation for this format

UML Diagram (Legend)

EligibilityRequest (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Priority ?? »Patient Resourcepatient : Reference [0..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientorganization : Reference [0..1] « Organization »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »Facility where the services were providedfacility : Reference [0..1] « Location »Financial instrument by which payment information for health carecoverage : Reference [0..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]Dental, Vision, Medical, Pharmacy, Rehab etcbenefitCategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcbenefitSubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »

XML Template

<EligibilityRequest 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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <benefitCategory><!-- 0..1 CodeableConcept Benefit Category --></benefitCategory>
 <benefitSubCategory><!-- 0..1 CodeableConcept Benefit SubCategory --></benefitSubCategory>
</EligibilityRequest>

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ 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 ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:EligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # 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.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityRequest.enterer [ Reference(Practitioner) ]; # 0..1 Author
  fhir:EligibilityRequest.provider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:EligibilityRequest.organization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:EligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:EligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:EligibilityRequest.coverage [ Reference(Coverage) ]; # 0..1 Insurance or medical plan
  fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement
  fhir:EligibilityRequest.benefitCategory [ CodeableConcept ]; # 0..1 Benefit Category
  fhir:EligibilityRequest.benefitSubCategory [ CodeableConcept ]; # 0..1 Benefit SubCategory
]

Changes since DSTU2

EligibilityRequest
EligibilityRequest.status added Element
EligibilityRequest.priority added Element
EligibilityRequest.patient added Element
EligibilityRequest.serviced[x] added Element
EligibilityRequest.enterer added Element
EligibilityRequest.insurer added Element
EligibilityRequest.facility added Element
EligibilityRequest.coverage added Element
EligibilityRequest.businessArrangement added Element
EligibilityRequest.benefitCategory added Element
EligibilityRequest.benefitSubCategory added Element
EligibilityRequest.ruleset deleted
EligibilityRequest.originalRuleset deleted
EligibilityRequest.target deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityRequest DomainResourceEligibility request
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... priority 0..1CodeableConceptDesired processing priority
Priority Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... provider 0..1Reference(Practitioner)Responsible practitioner
... organization 0..1Reference(Organization)Responsible organization
... insurer 0..1Reference(Organization)Target
... facility 0..1Reference(Location)Servicing Facility
... coverage 0..1Reference(Coverage)Insurance or medical plan
... businessArrangement 0..1stringBusiness agreement
... benefitCategory 0..1CodeableConceptBenefit Category
Benefit Category Codes (Example)
... benefitSubCategory 0..1CodeableConceptBenefit SubCategory
Benefit SubCategory Codes (Example)

doco Documentation for this format

UML Diagram (Legend)

EligibilityRequest (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Priority ?? »Patient Resourcepatient : Reference [0..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientorganization : Reference [0..1] « Organization »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »Facility where the services were providedfacility : Reference [0..1] « Location »Financial instrument by which payment information for health carecoverage : Reference [0..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]Dental, Vision, Medical, Pharmacy, Rehab etcbenefitCategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcbenefitSubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »

XML Template

<EligibilityRequest 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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <benefitCategory><!-- 0..1 CodeableConcept Benefit Category --></benefitCategory>
 <benefitSubCategory><!-- 0..1 CodeableConcept Benefit SubCategory --></benefitSubCategory>
</EligibilityRequest>

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ 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 ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:EligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # 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.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityRequest.enterer [ Reference(Practitioner) ]; # 0..1 Author
  fhir:EligibilityRequest.provider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:EligibilityRequest.organization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:EligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:EligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:EligibilityRequest.coverage [ Reference(Coverage) ]; # 0..1 Insurance or medical plan
  fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement
  fhir:EligibilityRequest.benefitCategory [ CodeableConcept ]; # 0..1 Benefit Category
  fhir:EligibilityRequest.benefitSubCategory [ CodeableConcept ]; # 0..1 Benefit SubCategory
]

Changes since DSTU2

EligibilityRequest
EligibilityRequest.status added Element
EligibilityRequest.priority added Element
EligibilityRequest.patient added Element
EligibilityRequest.serviced[x] added Element
EligibilityRequest.enterer added Element
EligibilityRequest.insurer added Element
EligibilityRequest.facility added Element
EligibilityRequest.coverage added Element
EligibilityRequest.businessArrangement added Element
EligibilityRequest.benefitCategory added Element
EligibilityRequest.benefitSubCategory added Element
EligibilityRequest.ruleset deleted
EligibilityRequest.originalRuleset deleted
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), JSON-LD (for RDF as JSON-LD),

13.4.2.1 Terminology Bindings

PathDefinitionTypeReference
EligibilityRequest.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
EligibilityRequest.priority The timeliness with which processing is required: STAT, normal, DeferredExamplePriority Codes
EligibilityRequest.benefitCategory Benefit categories such as: oral, medical, vision etc.ExampleBenefit Category Codes
EligibilityRequest.benefitSubCategory Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory Codes

13.4.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPathsIn Common
createddateThe creation date for the EOBEligibilityRequest.created
facilityreferenceFacility responsible for the goods and servicesEligibilityRequest.facility
(Location)
identifiertokenThe business identifier of the EligibilityEligibilityRequest.identifier
organizationreferenceThe reference to the providing organizationEligibilityRequest.organization
(Organization)
patientreferenceThe reference to the patientEligibilityRequest.patient
(Patient)
providerreferenceThe reference to the providerEligibilityRequest.provider
(Practitioner)