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

13.5 Resource EligibilityResponse - Content

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

This resource provides eligibility and plan details from the processing of an Eligibility resource.

13.5.1 Scope and Usage

The EligibilityResponse resource provides eligibility and plan details from the processing of an EligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy details.

13.5.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityResponse DomainResourceEligibilityResponse resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... created 0..1dateTimeCreation date
... requestProvider 0..1Reference(Practitioner)Responsible practitioner
... requestOrganization 0..1Reference(Organization)Responsible organization
... request 0..1Reference(EligibilityRequest)Eligibility reference
... outcome 0..1CodeableConceptcomplete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer 0..1Reference(Organization)Insurer
... inforce 0..1booleanCoverage inforce
... insurance 0..*BackboneElementDetails by insurance coverage
.... coverage 0..1Reference(Coverage)Updated Coverage details
.... contract 0..1Reference(Contract)Contract details
.... benefitBalance 0..*BackboneElementBenefits by Category
..... category 1..1CodeableConceptBenefit Category
Benefit Category Codes (Example)
..... subCategory 0..1CodeableConceptBenefit SubCategory
Benefit SubCategory Codes (Example)
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit
..... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
..... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
..... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
..... financial 0..*BackboneElementBenefit Summary
...... type 1..1CodeableConceptDeductable, visits, benefit amount
Benefit Type Codes (Example)
...... benefit[x] 0..1Benefits allowed
....... benefitUnsignedIntunsignedInt
....... benefitStringstring
....... benefitMoneyMoney
...... benefitUsed[x] 0..1Benefits used
....... benefitUsedUnsignedIntunsignedInt
....... benefitUsedMoneyMoney
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Required)
... error 0..*BackboneElementProcessing errors
.... code 1..1CodeableConceptError code detailing processing issues
Adjudication Error Codes (Required)

doco Documentation for this format

UML Diagram (Legend)

EligibilityResponse (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 ! »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientrequestOrganization : Reference [0..1] « Organization »Original request resource referencerequest : Reference [0..1] « EligibilityRequest »Transaction status: error, completeoutcome : CodeableConcept [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]The Insurer who produced this adjudicated responseinsurer : Reference [0..1] « 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 form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Required)Form ! »InsuranceA suite of updated or additional Coverages from the Insurercoverage : Reference [0..1] « Coverage »The contract resource which may provide more detailed informationcontract : Reference [0..1] « Contract »BenefitsDental, Vision, Medical, Pharmacy, Rehab etccategory : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcsubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefit, for example MED01, or DENT2name : string [0..1]A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'description : string [0..1]Network designationnetwork : CodeableConcept [0..1] « Code to classify in or out of network services (Strength=Example)Network Type ?? »Unit designation: individual or familyunit : CodeableConcept [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 : CodeableConcept [0..1] « Coverage unit - annual, lifetime (Strength=Example)Benefit Term ?? »BenefitDeductable, visits, benefit amounttype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)Benefit Type ?? »Benefits allowedbenefit[x] : Type [0..1] « unsignedInt|string|Money »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|Money »ErrorsAn error code,from a specified code system, which details why the eligibility check could not be performedcode : CodeableConcept [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..*]The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurerinsurance[0..*]Mutually exclusive with Services Provided (Item)error[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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(EligibilityRequest) Eligibility reference --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 0..1 Reference(Organization) Insurer --></insurer>
 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce -->
 <insurance>  <!-- 0..* Details by insurance coverage -->
  <coverage><!-- 0..1 Reference(Coverage) Updated Coverage details --></coverage>
  <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
  <benefitBalance>  <!-- 0..* Benefits by Category -->
   <category><!-- 1..1 CodeableConcept Benefit Category --></category>
   <subCategory><!-- 0..1 CodeableConcept Benefit SubCategory --></subCategory>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <financial>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
    <benefit[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></benefit[x]>
    <benefitUsed[x]><!-- 0..1 unsignedInt|Money Benefits used --></benefitUsed[x]>
   </financial>
  </benefitBalance>
 </insurance>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept 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
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "created" : "<dateTime>", // Creation date
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(EligibilityRequest) }, // Eligibility reference
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer
  "inforce" : <boolean>, // Coverage inforce
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "benefitBalance" : [{ // Benefits by Category
      "category" : { CodeableConcept }, // R!  Benefit Category
      "subCategory" : { CodeableConcept }, // Benefit SubCategory
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "financial" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount
        // benefit[x]: Benefits allowed. One of these 3:
        "benefitUnsignedInt" : "<unsignedInt>",
        "benefitString" : "<string>",
        "benefitMoney" : { Money },
        // benefitUsed[x]: Benefits used. One of these 2:
        "benefitUsedUnsignedInt" : "<unsignedInt>"
        "benefitUsedMoney" : { Money }
      }]
    }]
  }],
  "form" : { CodeableConcept }, // Printed Form Identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle Template

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


[ a fhir:EligibilityResponse;
  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:EligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:EligibilityResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:EligibilityResponse.request [ Reference(EligibilityRequest) ]; # 0..1 Eligibility reference
  fhir:EligibilityResponse.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce
  fhir:EligibilityResponse.insurance [ # 0..* Details by insurance coverage
    fhir:EligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 0..1 Updated Coverage details
    fhir:EligibilityResponse.insurance.contract [ Reference(Contract) ]; # 0..1 Contract details
    fhir:EligibilityResponse.insurance.benefitBalance [ # 0..* Benefits by Category
      fhir:EligibilityResponse.insurance.benefitBalance.category [ CodeableConcept ]; # 1..1 Benefit Category
      fhir:EligibilityResponse.insurance.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Benefit SubCategory
      fhir:EligibilityResponse.insurance.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:EligibilityResponse.insurance.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
      fhir:EligibilityResponse.insurance.benefitBalance.description [ string ]; # 0..1 Description of the benefit
      fhir:EligibilityResponse.insurance.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:EligibilityResponse.insurance.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:EligibilityResponse.insurance.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:EligibilityResponse.insurance.benefitBalance.financial [ # 0..* Benefit Summary
        fhir:EligibilityResponse.insurance.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Deductable, visits, benefit amount
        # EligibilityResponse.insurance.benefitBalance.financial.benefit[x] : 0..1 Benefits allowed. One of these 3
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitString [ string ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitMoney [ Money ]
        # EligibilityResponse.insurance.benefitBalance.financial.benefitUsed[x] : 0..1 Benefits used. One of these 2
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitUsedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitUsedMoney [ Money ]
      ], ...;
    ], ...;
  ], ...;
  fhir:EligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:EligibilityResponse.error [ # 0..* Processing errors
    fhir:EligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since DSTU2

EligibilityResponse
EligibilityResponse.status added Element
EligibilityResponse.outcome Type changed from code to CodeableConcept
EligibilityResponse.insurer added Element
EligibilityResponse.inforce added Element
EligibilityResponse.insurance added Element
EligibilityResponse.insurance.coverage added Element
EligibilityResponse.insurance.contract added Element
EligibilityResponse.insurance.benefitBalance added Element
EligibilityResponse.insurance.benefitBalance.category added Element
EligibilityResponse.insurance.benefitBalance.subCategory added Element
EligibilityResponse.insurance.benefitBalance.excluded added Element
EligibilityResponse.insurance.benefitBalance.name added Element
EligibilityResponse.insurance.benefitBalance.description added Element
EligibilityResponse.insurance.benefitBalance.network added Element
EligibilityResponse.insurance.benefitBalance.unit added Element
EligibilityResponse.insurance.benefitBalance.term added Element
EligibilityResponse.insurance.benefitBalance.financial added Element
EligibilityResponse.insurance.benefitBalance.financial.type added Element
EligibilityResponse.insurance.benefitBalance.financial.benefit[x] added Element
EligibilityResponse.insurance.benefitBalance.financial.benefitUsed[x] added Element
EligibilityResponse.form added Element
EligibilityResponse.error added Element
EligibilityResponse.error.code added Element
EligibilityResponse.ruleset deleted
EligibilityResponse.originalRuleset deleted
EligibilityResponse.organization deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityResponse DomainResourceEligibilityResponse resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... created 0..1dateTimeCreation date
... requestProvider 0..1Reference(Practitioner)Responsible practitioner
... requestOrganization 0..1Reference(Organization)Responsible organization
... request 0..1Reference(EligibilityRequest)Eligibility reference
... outcome 0..1CodeableConceptcomplete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer 0..1Reference(Organization)Insurer
... inforce 0..1booleanCoverage inforce
... insurance 0..*BackboneElementDetails by insurance coverage
.... coverage 0..1Reference(Coverage)Updated Coverage details
.... contract 0..1Reference(Contract)Contract details
.... benefitBalance 0..*BackboneElementBenefits by Category
..... category 1..1CodeableConceptBenefit Category
Benefit Category Codes (Example)
..... subCategory 0..1CodeableConceptBenefit SubCategory
Benefit SubCategory Codes (Example)
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit
..... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
..... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
..... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
..... financial 0..*BackboneElementBenefit Summary
...... type 1..1CodeableConceptDeductable, visits, benefit amount
Benefit Type Codes (Example)
...... benefit[x] 0..1Benefits allowed
....... benefitUnsignedIntunsignedInt
....... benefitStringstring
....... benefitMoneyMoney
...... benefitUsed[x] 0..1Benefits used
....... benefitUsedUnsignedIntunsignedInt
....... benefitUsedMoneyMoney
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Required)
... error 0..*BackboneElementProcessing errors
.... code 1..1CodeableConceptError code detailing processing issues
Adjudication Error Codes (Required)

doco Documentation for this format

UML Diagram (Legend)

EligibilityResponse (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 ! »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientrequestOrganization : Reference [0..1] « Organization »Original request resource referencerequest : Reference [0..1] « EligibilityRequest »Transaction status: error, completeoutcome : CodeableConcept [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]The Insurer who produced this adjudicated responseinsurer : Reference [0..1] « 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 form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Required)Form ! »InsuranceA suite of updated or additional Coverages from the Insurercoverage : Reference [0..1] « Coverage »The contract resource which may provide more detailed informationcontract : Reference [0..1] « Contract »BenefitsDental, Vision, Medical, Pharmacy, Rehab etccategory : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcsubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefit, for example MED01, or DENT2name : string [0..1]A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'description : string [0..1]Network designationnetwork : CodeableConcept [0..1] « Code to classify in or out of network services (Strength=Example)Network Type ?? »Unit designation: individual or familyunit : CodeableConcept [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 : CodeableConcept [0..1] « Coverage unit - annual, lifetime (Strength=Example)Benefit Term ?? »BenefitDeductable, visits, benefit amounttype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)Benefit Type ?? »Benefits allowedbenefit[x] : Type [0..1] « unsignedInt|string|Money »Benefits usedbenefitUsed[x] : Type [0..1] « unsignedInt|Money »ErrorsAn error code,from a specified code system, which details why the eligibility check could not be performedcode : CodeableConcept [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..*]The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurerinsurance[0..*]Mutually exclusive with Services Provided (Item)error[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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(EligibilityRequest) Eligibility reference --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 0..1 Reference(Organization) Insurer --></insurer>
 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce -->
 <insurance>  <!-- 0..* Details by insurance coverage -->
  <coverage><!-- 0..1 Reference(Coverage) Updated Coverage details --></coverage>
  <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
  <benefitBalance>  <!-- 0..* Benefits by Category -->
   <category><!-- 1..1 CodeableConcept Benefit Category --></category>
   <subCategory><!-- 0..1 CodeableConcept Benefit SubCategory --></subCategory>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <financial>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
    <benefit[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></benefit[x]>
    <benefitUsed[x]><!-- 0..1 unsignedInt|Money Benefits used --></benefitUsed[x]>
   </financial>
  </benefitBalance>
 </insurance>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept 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
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "created" : "<dateTime>", // Creation date
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(EligibilityRequest) }, // Eligibility reference
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer
  "inforce" : <boolean>, // Coverage inforce
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "benefitBalance" : [{ // Benefits by Category
      "category" : { CodeableConcept }, // R!  Benefit Category
      "subCategory" : { CodeableConcept }, // Benefit SubCategory
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "financial" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount
        // benefit[x]: Benefits allowed. One of these 3:
        "benefitUnsignedInt" : "<unsignedInt>",
        "benefitString" : "<string>",
        "benefitMoney" : { Money },
        // benefitUsed[x]: Benefits used. One of these 2:
        "benefitUsedUnsignedInt" : "<unsignedInt>"
        "benefitUsedMoney" : { Money }
      }]
    }]
  }],
  "form" : { CodeableConcept }, // Printed Form Identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle Template

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


[ a fhir:EligibilityResponse;
  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:EligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:EligibilityResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:EligibilityResponse.request [ Reference(EligibilityRequest) ]; # 0..1 Eligibility reference
  fhir:EligibilityResponse.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce
  fhir:EligibilityResponse.insurance [ # 0..* Details by insurance coverage
    fhir:EligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 0..1 Updated Coverage details
    fhir:EligibilityResponse.insurance.contract [ Reference(Contract) ]; # 0..1 Contract details
    fhir:EligibilityResponse.insurance.benefitBalance [ # 0..* Benefits by Category
      fhir:EligibilityResponse.insurance.benefitBalance.category [ CodeableConcept ]; # 1..1 Benefit Category
      fhir:EligibilityResponse.insurance.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Benefit SubCategory
      fhir:EligibilityResponse.insurance.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:EligibilityResponse.insurance.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
      fhir:EligibilityResponse.insurance.benefitBalance.description [ string ]; # 0..1 Description of the benefit
      fhir:EligibilityResponse.insurance.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:EligibilityResponse.insurance.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:EligibilityResponse.insurance.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:EligibilityResponse.insurance.benefitBalance.financial [ # 0..* Benefit Summary
        fhir:EligibilityResponse.insurance.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Deductable, visits, benefit amount
        # EligibilityResponse.insurance.benefitBalance.financial.benefit[x] : 0..1 Benefits allowed. One of these 3
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitString [ string ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitMoney [ Money ]
        # EligibilityResponse.insurance.benefitBalance.financial.benefitUsed[x] : 0..1 Benefits used. One of these 2
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitUsedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.benefitUsedMoney [ Money ]
      ], ...;
    ], ...;
  ], ...;
  fhir:EligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:EligibilityResponse.error [ # 0..* Processing errors
    fhir:EligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since DSTU2

EligibilityResponse
EligibilityResponse.status added Element
EligibilityResponse.outcome Type changed from code to CodeableConcept
EligibilityResponse.insurer added Element
EligibilityResponse.inforce added Element
EligibilityResponse.insurance added Element
EligibilityResponse.insurance.coverage added Element
EligibilityResponse.insurance.contract added Element
EligibilityResponse.insurance.benefitBalance added Element
EligibilityResponse.insurance.benefitBalance.category added Element
EligibilityResponse.insurance.benefitBalance.subCategory added Element
EligibilityResponse.insurance.benefitBalance.excluded added Element
EligibilityResponse.insurance.benefitBalance.name added Element
EligibilityResponse.insurance.benefitBalance.description added Element
EligibilityResponse.insurance.benefitBalance.network added Element
EligibilityResponse.insurance.benefitBalance.unit added Element
EligibilityResponse.insurance.benefitBalance.term added Element
EligibilityResponse.insurance.benefitBalance.financial added Element
EligibilityResponse.insurance.benefitBalance.financial.type added Element
EligibilityResponse.insurance.benefitBalance.financial.benefit[x] added Element
EligibilityResponse.insurance.benefitBalance.financial.benefitUsed[x] added Element
EligibilityResponse.form added Element
EligibilityResponse.error added Element
EligibilityResponse.error.code added Element
EligibilityResponse.ruleset deleted
EligibilityResponse.originalRuleset deleted
EligibilityResponse.organization 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),

13.5.2.1 Terminology Bindings

PathDefinitionTypeReference
EligibilityResponse.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
EligibilityResponse.outcome The outcome of the processing.RequiredRemittanceOutcome
EligibilityResponse.insurance.benefitBalance.category Benefit categories such as: oral, medical, vision etc.ExampleBenefit Category Codes
EligibilityResponse.insurance.benefitBalance.subCategory Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory Codes
EligibilityResponse.insurance.benefitBalance.network Code to classify in or out of network servicesExampleNetwork Type Codes
EligibilityResponse.insurance.benefitBalance.unit Unit covered/serviced - individual or familyExampleUnit Type Codes
EligibilityResponse.insurance.benefitBalance.term Coverage unit - annual, lifetimeExampleBenefit Term Codes
EligibilityResponse.insurance.benefitBalance.financial.type Deductable, visits, co-pay, etc.ExampleBenefit Type Codes
EligibilityResponse.form The forms codes.RequiredForm Codes
EligibilityResponse.error.code The error codes for adjudication processing.RequiredAdjudication Error Codes

13.5.3 Search Parameters

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

NameTypeDescriptionPathsIn Common
createddateThe creation dateEligibilityResponse.created
dispositionstringThe contents of the disposition messageEligibilityResponse.disposition
identifiertokenThe business identifierEligibilityResponse.identifier
insurerreferenceThe organization which generated this resourceEligibilityResponse.insurer
(Organization)
outcometokenThe processing outcomeEligibilityResponse.outcome
requestreferenceThe EligibilityRequest referenceEligibilityResponse.request
(EligibilityRequest)
request-organizationreferenceThe EligibilityRequest organizationEligibilityResponse.requestOrganization
(Organization)
request-providerreferenceThe EligibilityRequest providerEligibilityResponse.requestProvider
(Practitioner)