R4 Draft for Comment

This 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

13.3 Resource EligibilityResponse - Content

Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Practitioner

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

13.3.1 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.

For Balloters: The optional Authorization subclass has been addded for comment ballot review. The EligibilityResponse would return a boolean indicating whether pre-authorization is required and an optional text element woud convey and special instructions for each of the billable services provided in the EligibilityRequest.

13.3.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityResponse TUDomainResourceEligibilityResponse resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... 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..1codecomplete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer 0..1Reference(Organization)Insurer issuing the coverage
... inforce 0..1booleanCoverage inforce indicator
... 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..1CodeableConceptType of services covered
Benefit Category Codes (Example)
..... subCategory 0..1CodeableConceptDetailed services covered within the type
Benefit SubCategory Codes (Example)
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit or services covered
..... 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)
...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedMoneyMoney
... preAuthRef 0..1stringPre-Authorization/Determination Reference
... authorization 0..*BackboneElementServices which may require prior authorization
.... authorizationSequence 1..1positiveIntProcedure sequence for reference
.... required 1..1booleanAuthorization required flag
.... note 0..*AnnotationComments and instructions
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Example)
... error 0..*BackboneElementProcessing errors
.... code 1..1CodeableConceptError code detailing processing issues
Adjudication Error Codes (Example)

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 : code [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]A reference from the Insurer to which these services pertainpreAuthRef : string [0..1]The form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Example)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 allowedallowed[x] : Type [0..1] « unsignedInt|string|Money »Benefits usedused[x] : Type [0..1] « unsignedInt|Money »AuthorizationSequence of procedures which serves to order and provide a linkauthorizationSequence : positiveInt [1..1]A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service deliveryrequired : boolean [1..1]Any comments regarding information or actions assciated with the pre-authorizationnote : Annotation [0..*]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=Example)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..*]A list of billable services for which an authorization prior to service delivery may be required by the payorauthorization[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 value="[code]"/><!-- 0..1 complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 0..1 Reference(Organization) Insurer issuing the coverage --></insurer>
 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
 <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 Type of services covered --></category>
   <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></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 or services covered -->
   <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>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
   </financial>
  </benefitBalance>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference -->
 <authorization>  <!-- 0..* Services which may require prior authorization -->
  <authorizationSequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <required value="[boolean]"/><!-- 1..1 Authorization required flag -->
  <note><!-- 0..* Annotation Comments and instructions --></note>
 </authorization>
 <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" : "<code>", // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer issuing the coverage
  "inforce" : <boolean>, // Coverage inforce indicator
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "benefitBalance" : [{ // Benefits by Category
      "category" : { CodeableConcept }, // R!  Type of services covered
      "subCategory" : { CodeableConcept }, // Detailed services covered within the type
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "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
        // allowed[x]: Benefits allowed. One of these 3:
        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 2:
        "usedUnsignedInt" : "<unsignedInt>"
        "usedMoney" : { Money }
      }]
    }]
  }],
  "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference
  "authorization" : [{ // Services which may require prior authorization
    "authorizationSequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "required" : <boolean>, // R!  Authorization required flag
    "note" : [{ Annotation }] // Comments and instructions
  }],
  "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 [ code ]; # 0..1 complete | error | partial
  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer issuing the coverage
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce indicator
  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 Type of services covered
      fhir:EligibilityResponse.insurance.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
      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 or services covered
      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.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedString [ string ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedMoney [ Money ]
        # EligibilityResponse.insurance.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedMoney [ Money ]
      ], ...;
    ], ...;
  ], ...;
  fhir:EligibilityResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference
  fhir:EligibilityResponse.authorization [ # 0..* Services which may require prior authorization
    fhir:EligibilityResponse.authorization.authorizationSequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:EligibilityResponse.authorization.required [ boolean ]; # 1..1 Authorization required flag
    fhir:EligibilityResponse.authorization.note [ Annotation ], ... ; # 0..* Comments and instructions
  ], ...;
  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.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.allowed[x]
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.used[x]
  • Added Element
EligibilityResponse.preAuthRef
  • Added Element
EligibilityResponse.authorization
  • Added Element
EligibilityResponse.authorization.authorizationSequence
  • Added Element
EligibilityResponse.authorization.required
  • Added Element
EligibilityResponse.authorization.note
  • 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

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityResponse TUDomainResourceEligibilityResponse resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... 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..1codecomplete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer 0..1Reference(Organization)Insurer issuing the coverage
... inforce 0..1booleanCoverage inforce indicator
... 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..1CodeableConceptType of services covered
Benefit Category Codes (Example)
..... subCategory 0..1CodeableConceptDetailed services covered within the type
Benefit SubCategory Codes (Example)
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit or services covered
..... 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)
...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedMoneyMoney
... preAuthRef 0..1stringPre-Authorization/Determination Reference
... authorization 0..*BackboneElementServices which may require prior authorization
.... authorizationSequence 1..1positiveIntProcedure sequence for reference
.... required 1..1booleanAuthorization required flag
.... note 0..*AnnotationComments and instructions
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Example)
... error 0..*BackboneElementProcessing errors
.... code 1..1CodeableConceptError code detailing processing issues
Adjudication Error Codes (Example)

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 : code [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]A reference from the Insurer to which these services pertainpreAuthRef : string [0..1]The form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Example)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 allowedallowed[x] : Type [0..1] « unsignedInt|string|Money »Benefits usedused[x] : Type [0..1] « unsignedInt|Money »AuthorizationSequence of procedures which serves to order and provide a linkauthorizationSequence : positiveInt [1..1]A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service deliveryrequired : boolean [1..1]Any comments regarding information or actions assciated with the pre-authorizationnote : Annotation [0..*]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=Example)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..*]A list of billable services for which an authorization prior to service delivery may be required by the payorauthorization[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 value="[code]"/><!-- 0..1 complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 0..1 Reference(Organization) Insurer issuing the coverage --></insurer>
 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
 <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 Type of services covered --></category>
   <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></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 or services covered -->
   <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>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
   </financial>
  </benefitBalance>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference -->
 <authorization>  <!-- 0..* Services which may require prior authorization -->
  <authorizationSequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <required value="[boolean]"/><!-- 1..1 Authorization required flag -->
  <note><!-- 0..* Annotation Comments and instructions --></note>
 </authorization>
 <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" : "<code>", // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer issuing the coverage
  "inforce" : <boolean>, // Coverage inforce indicator
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "benefitBalance" : [{ // Benefits by Category
      "category" : { CodeableConcept }, // R!  Type of services covered
      "subCategory" : { CodeableConcept }, // Detailed services covered within the type
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "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
        // allowed[x]: Benefits allowed. One of these 3:
        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 2:
        "usedUnsignedInt" : "<unsignedInt>"
        "usedMoney" : { Money }
      }]
    }]
  }],
  "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference
  "authorization" : [{ // Services which may require prior authorization
    "authorizationSequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "required" : <boolean>, // R!  Authorization required flag
    "note" : [{ Annotation }] // Comments and instructions
  }],
  "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 [ code ]; # 0..1 complete | error | partial
  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer issuing the coverage
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce indicator
  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 Type of services covered
      fhir:EligibilityResponse.insurance.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
      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 or services covered
      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.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedString [ string ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedMoney [ Money ]
        # EligibilityResponse.insurance.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedMoney [ Money ]
      ], ...;
    ], ...;
  ], ...;
  fhir:EligibilityResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference
  fhir:EligibilityResponse.authorization [ # 0..* Services which may require prior authorization
    fhir:EligibilityResponse.authorization.authorizationSequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:EligibilityResponse.authorization.required [ boolean ]; # 1..1 Authorization required flag
    fhir:EligibilityResponse.authorization.note [ Annotation ], ... ; # 0..* Comments and instructions
  ], ...;
  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.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.allowed[x]
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.used[x]
  • Added Element
EligibilityResponse.preAuthRef
  • Added Element
EligibilityResponse.authorization
  • Added Element
EligibilityResponse.authorization.authorizationSequence
  • Added Element
EligibilityResponse.authorization.required
  • Added Element
EligibilityResponse.authorization.note
  • 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

This analysis is available as XML or JSON.

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

13.3.2.1 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.ExampleForm Codes
EligibilityResponse.error.code The error codes for adjudication processing.ExampleAdjudication Error Codes

13.3.3 Search Parameters

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

NameTypeDescriptionExpressionIn 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)
statustokenThe EligibilityRequest statusEligibilityResponse.status