R4 Draft for Comment
FinancialThis page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). 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: 2 | Trial Use | Compartments: Patient, Practitioner |
The EligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an EligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
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.
For Balloters: The optional Authorization subclass has been added for comment ballot review. It is intended to convey the billable services which may be performed and for which the provider wishes to determine whether it needs to submit a prior authorization (pre-authorization) request. The EligibilityResponse would return a boolean flag indicating whether prior authorization is required and an optional text element would convey any special instructions.
This resource is referenced by eligibilityresponse
Structure
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]"/><!-- 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 Type of services covered --></benefitCategory> <benefitSubCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></benefitSubCategory> <authorization> <!-- 0..* Services which may require prior authorization --> <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference --> <service><!-- 1..1 CodeableConcept Billing Code --></service> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility> </authorization> </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>", // active | cancelled | draft | entered-in-error
"priority" : { CodeableConcept }, // Desired processing priority
"patient" : { Reference(Patient) }, // The subject of the Products and Services
// serviced[x]: Estimated date or dates of Service. One of these 2:
"servicedDate" : "<date>",
"servicedPeriod" : { Period },
"created" : "<dateTime>", // Creation date
"enterer" : { Reference(Practitioner) }, // Author
"provider" : { Reference(Practitioner) }, // Responsible practitioner
"organization" : { Reference(Organization) }, // Responsible organization
"insurer" : { Reference(Organization) }, // Target
"facility" : { Reference(Location) }, // Servicing Facility
"coverage" : { Reference(Coverage) }, // Insurance or medical plan
"businessArrangement" : "<string>", // Business agreement
"benefitCategory" : { CodeableConcept }, // Type of services covered
"benefitSubCategory" : { CodeableConcept }, // Detailed services covered within the type
"authorization" : [{ // Services which may require prior authorization
"sequence" : "<positiveInt>", // R! Procedure sequence for reference
"service" : { CodeableConcept }, // R! Billing Code
"modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
"unitPrice" : { Money }, // Fee, charge or cost per point
"facility" : { Reference(Location|Organization) } // Servicing Facility
}]
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .
Changes since DSTU2
| EligibilityRequest | |
| EligibilityRequest.status |
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| EligibilityRequest.priority |
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| EligibilityRequest.patient |
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| EligibilityRequest.serviced[x] |
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| EligibilityRequest.enterer |
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| EligibilityRequest.insurer |
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| EligibilityRequest.facility |
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| EligibilityRequest.coverage |
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| EligibilityRequest.businessArrangement |
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| EligibilityRequest.benefitCategory |
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| EligibilityRequest.benefitSubCategory |
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| EligibilityRequest.authorization |
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| EligibilityRequest.authorization.sequence |
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| EligibilityRequest.authorization.service |
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| EligibilityRequest.authorization.modifier |
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| EligibilityRequest.authorization.unitPrice |
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| EligibilityRequest.authorization.facility |
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| EligibilityRequest.ruleset |
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| EligibilityRequest.originalRuleset |
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| EligibilityRequest.target |
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See the Full Difference for further information
Structure
XML Template
<EligibilityRequest xmlns="http://hl7.org/fhir">
JSON Template
{
"resourceType" : "EligibilityRequest",
// 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
"priority" : { CodeableConcept }, // Desired processing priority
"patient" : { Reference(Patient) }, // The subject of the Products and Services
// serviced[x]: Estimated date or dates of Service. One of these 2:
"servicedDate" : "<date>",
"servicedPeriod" : { Period },
"created" : "<dateTime>", // Creation date
"enterer" : { Reference(Practitioner) }, // Author
"provider" : { Reference(Practitioner) }, // Responsible practitioner
"organization" : { Reference(Organization) }, // Responsible organization
"insurer" : { Reference(Organization) }, // Target
"facility" : { Reference(Location) }, // Servicing Facility
"coverage" : { Reference(Coverage) }, // Insurance or medical plan
"businessArrangement" : "<string>", // Business agreement
"benefitCategory" : { CodeableConcept }, // Type of services covered
"benefitSubCategory" : { CodeableConcept }, // Detailed services covered within the type
"authorization" : [{ // Services which may require prior authorization
"sequence" : "<positiveInt>", // R! Procedure sequence for reference
"service" : { CodeableConcept }, // R! Billing Code
"modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
"unitPrice" : { Money }, // Fee, charge or cost per point
"facility" : { Reference(Location|Organization) } // Servicing Facility
}]
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .
Changes since DSTU2
| EligibilityRequest | |
| EligibilityRequest.status |
|
| EligibilityRequest.priority |
|
| EligibilityRequest.patient |
|
| EligibilityRequest.serviced[x] |
|
| EligibilityRequest.enterer |
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| EligibilityRequest.insurer |
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| EligibilityRequest.facility |
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| EligibilityRequest.coverage |
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| EligibilityRequest.businessArrangement |
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| EligibilityRequest.benefitCategory |
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| EligibilityRequest.benefitSubCategory |
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| EligibilityRequest.authorization |
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| EligibilityRequest.authorization.sequence |
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| EligibilityRequest.authorization.service |
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| EligibilityRequest.authorization.modifier |
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| EligibilityRequest.authorization.unitPrice |
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| EligibilityRequest.authorization.facility |
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| EligibilityRequest.ruleset |
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| EligibilityRequest.originalRuleset |
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| EligibilityRequest.target |
|
See the Full Difference for further information
Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis
| Path | Definition | Type | Reference |
|---|---|---|---|
| EligibilityRequest.status | A code specifying the state of the resource instance. | Required | Financial Resource Status Codes |
| EligibilityRequest.priority | The timeliness with which processing is required: STAT, normal, Deferred | Example | Process 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 |
| EligibilityRequest.authorization.service | Allowable service and product codes | Example | USCLS Codes |
| EligibilityRequest.authorization.modifier | Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | Example | Modifier type 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 | Expression | In Common |
| created | date | The creation date for the EOB | EligibilityRequest.created | |
| enterer | reference | The party who is responsible for the request | EligibilityRequest.enterer (Practitioner) | |
| facility | reference | Facility responsible for the goods and services | EligibilityRequest.facility (Location) | |
| identifier | token | The business identifier of the Eligibility | EligibilityRequest.identifier | |
| organization | reference | The reference to the providing organization | EligibilityRequest.organization (Organization) | |
| patient | reference | The reference to the patient | EligibilityRequest.patient (Patient) | |
| provider | reference | The reference to the provider | EligibilityRequest.provider (Practitioner) | |
| status | token | The status of the EligibilityRequest | EligibilityRequest.status |
®© HL7.org 2011+. FHIR Release 4 Draft for Comment (Jan-2018 v3.2.0-12885) generated on Wed, Dec 20, 2017 15:57+1100. QA Page
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