R4 Ballot #1 (Mixed Normative/Trial use)
FinancialThis page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). 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: N/A | Ballot Status: Informative | Compartments: Patient, Practitioner |
StructureDefinition for eligibilityrequest
{
"resourceType": "StructureDefinition",
"id": "EligibilityRequest",
"meta": {
"lastUpdated": "2018-04-03T12:05:46.262+10:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-ballot-status",
"valueString": "Trial Use"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
}
],
"url": "http://hl7.org/fhir/StructureDefinition/EligibilityRequest",
"name": "EligibilityRequest",
"status": "draft",
"date": "2018-04-03T12:05:46+10:00",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"description": "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.",
"fhirVersion": "3.3.0",
"mapping": [
{
"identity": "workflow",
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern"
},
{
"identity": "v2",
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "resource",
"abstract": false,
"type": "EligibilityRequest",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "EligibilityRequest",
"path": "EligibilityRequest",
"short": "Determine insurance validity and scope of coverage",
"definition": "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.",
"min": 0,
"max": "*",
"base": {
"path": "EligibilityRequest",
"min": 0,
"max": "*"
},
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource"
},
{
"key": "dom-3",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource",
"expression": "contained.all(('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists())",
"xpath": "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
"source": "DomainResource"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "workflow",
"map": "Request"
}
]
},
{
"id": "EligibilityRequest.id",
"path": "EligibilityRequest.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isModifier": false,
"isSummary": true
},
{
"id": "EligibilityRequest.meta",
"path": "EligibilityRequest.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isModifier": false,
"isSummary": true
},
{
"id": "EligibilityRequest.implicitRules",
"path": "EligibilityRequest.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.",
"comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary": true
},
{
"id": "EligibilityRequest.language",
"path": "EligibilityRequest.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/languages"
}
},
{
"id": "EligibilityRequest.text",
"path": "EligibilityRequest.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "EligibilityRequest.contained",
"path": "EligibilityRequest.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityRequest.extension",
"path": "EligibilityRequest.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityRequest.modifierExtension",
"path": "EligibilityRequest.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "Not known why this is labelled a modifier",
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityRequest.identifier",
"path": "EligibilityRequest.identifier",
"short": "Business Identifier",
"definition": "The Response business identifier.",
"min": 0,
"max": "*",
"base": {
"path": "EligibilityRequest.identifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Identifier"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
}
]
},
{
"id": "EligibilityRequest.status",
"path": "EligibilityRequest.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"requirements": "This element is labeled as a modifier because the status contains codes that mark the request as not currently valid.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.status",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isModifierReason": "This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "EligibilityRequestStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/fm-status"
},
"mapping": [
{
"identity": "workflow",
"map": "Request.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
}
]
},
{
"id": "EligibilityRequest.priority",
"path": "EligibilityRequest.priority",
"short": "Desired processing priority",
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.priority",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
}
],
"strength": "example",
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/process-priority"
},
"mapping": [
{
"identity": "workflow",
"map": "Request.priority"
},
{
"identity": "w5",
"map": "FiveWs.class"
}
]
},
{
"id": "EligibilityRequest.patient",
"path": "EligibilityRequest.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"comment": "1..1.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.patient",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.subject"
},
{
"identity": "w5",
"map": "FiveWs.subject[x]"
},
{
"identity": "w5",
"map": "FiveWs.subject"
}
]
},
{
"id": "EligibilityRequest.serviced[x]",
"path": "EligibilityRequest.serviced[x]",
"short": "Estimated date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.serviced[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
}
]
},
{
"id": "EligibilityRequest.created",
"path": "EligibilityRequest.created",
"short": "Creation date",
"definition": "The date when this resource was created.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.created",
"min": 0,
"max": "1"
},
"type": [
{
"code": "dateTime"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.authoredOn"
},
{
"identity": "w5",
"map": "FiveWs.recorded"
}
]
},
{
"id": "EligibilityRequest.enterer",
"path": "EligibilityRequest.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.enterer",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.author"
}
]
},
{
"id": "EligibilityRequest.provider",
"path": "EligibilityRequest.provider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.provider",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.requester"
},
{
"identity": "w5",
"map": "FiveWs.source"
}
]
},
{
"id": "EligibilityRequest.insurer",
"path": "EligibilityRequest.insurer",
"short": "Target",
"definition": "The Insurer who is target of the request.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.insurer",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.performer"
},
{
"identity": "w5",
"map": "FiveWs.who"
}
]
},
{
"id": "EligibilityRequest.facility",
"path": "EligibilityRequest.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.facility",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.where[x]"
}
]
},
{
"id": "EligibilityRequest.coverage",
"path": "EligibilityRequest.coverage",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"comment": "1..1.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.coverage",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Coverage"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "EligibilityRequest.businessArrangement",
"path": "EligibilityRequest.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.businessArrangement",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "EligibilityRequest.benefitCategory",
"path": "EligibilityRequest.benefitCategory",
"short": "Type of services covered",
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.benefitCategory",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
}
],
"strength": "example",
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-category"
}
},
{
"id": "EligibilityRequest.benefitSubCategory",
"path": "EligibilityRequest.benefitSubCategory",
"short": "Detailed services covered within the type",
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.benefitSubCategory",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
{
"id": "EligibilityRequest.authorization",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Authorization"
}
],
"path": "EligibilityRequest.authorization",
"short": "Services which may require prior authorization",
"definition": "A list of billable services for which an authorization prior to service delivery may be required by the payor.",
"min": 0,
"max": "*",
"base": {
"path": "EligibilityRequest.authorization",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "EligibilityRequest.authorization.id",
"path": "EligibilityRequest.authorization.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityRequest.authorization.extension",
"path": "EligibilityRequest.authorization.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityRequest.authorization.modifierExtension",
"path": "EligibilityRequest.authorization.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityRequest.authorization.sequence",
"path": "EligibilityRequest.authorization.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"min": 1,
"max": "1",
"base": {
"path": "EligibilityRequest.authorization.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "EligibilityRequest.authorization.service",
"path": "EligibilityRequest.authorization.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 1,
"max": "1",
"base": {
"path": "EligibilityRequest.authorization.service",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id": "EligibilityRequest.authorization.modifier",
"path": "EligibilityRequest.authorization.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"min": 0,
"max": "*",
"base": {
"path": "EligibilityRequest.authorization.modifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id": "EligibilityRequest.authorization.quantity",
"path": "EligibilityRequest.authorization.quantity",
"short": "Count of products or services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.authorization.quantity",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "EligibilityRequest.authorization.unitPrice",
"path": "EligibilityRequest.authorization.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.authorization.unitPrice",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Money"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "EligibilityRequest.authorization.facility",
"path": "EligibilityRequest.authorization.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.authorization.facility",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location",
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "EligibilityRequest.authorization.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "0;115"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "EligibilityRequest.authorization.diagnosis",
"short": "List of Diagnosis",
"definition": "List of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"base": {
"path": "EligibilityRequest.authorization.diagnosis",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "v2",
"map": "Request.reasonReference"
}
]
},
{
"id": "EligibilityRequest.authorization.diagnosis.id",
"path": "EligibilityRequest.authorization.diagnosis.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityRequest.authorization.diagnosis.extension",
"path": "EligibilityRequest.authorization.diagnosis.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityRequest.authorization.diagnosis.modifierExtension",
"path": "EligibilityRequest.authorization.diagnosis.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityRequest.authorization.diagnosis.diagnosis[x]",
"path": "EligibilityRequest.authorization.diagnosis.diagnosis[x]",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 0,
"max": "1",
"base": {
"path": "EligibilityRequest.authorization.diagnosis.diagnosis[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Condition"
]
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
}
],
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
]
},
"differential": {
"element": [
{
"id": "EligibilityRequest",
"path": "EligibilityRequest",
"short": "Determine insurance validity and scope of coverage",
"definition": "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.",
"min": 0,
"max": "*",
"mapping": [
{
"identity": "workflow",
"map": "Request"
}
]
},
{
"id": "EligibilityRequest.identifier",
"path": "EligibilityRequest.identifier",
"short": "Business Identifier",
"definition": "The Response business identifier.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
}
]
},
{
"id": "EligibilityRequest.status",
"path": "EligibilityRequest.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"requirements": "This element is labeled as a modifier because the status contains codes that mark the request as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isModifierReason": "This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "EligibilityRequestStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/fm-status"
},
"mapping": [
{
"identity": "workflow",
"map": "Request.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
}
]
},
{
"id": "EligibilityRequest.priority",
"path": "EligibilityRequest.priority",
"short": "Desired processing priority",
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
}
],
"strength": "example",
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/process-priority"
},
"mapping": [
{
"identity": "workflow",
"map": "Request.priority"
},
{
"identity": "w5",
"map": "FiveWs.class"
}
]
},
{
"id": "EligibilityRequest.patient",
"path": "EligibilityRequest.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"comment": "1..1.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.subject"
},
{
"identity": "w5",
"map": "FiveWs.subject[x]"
},
{
"identity": "w5",
"map": "FiveWs.subject"
}
]
},
{
"id": "EligibilityRequest.serviced[x]",
"path": "EligibilityRequest.serviced[x]",
"short": "Estimated date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
}
]
},
{
"id": "EligibilityRequest.created",
"path": "EligibilityRequest.created",
"short": "Creation date",
"definition": "The date when this resource was created.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.authoredOn"
},
{
"identity": "w5",
"map": "FiveWs.recorded"
}
]
},
{
"id": "EligibilityRequest.enterer",
"path": "EligibilityRequest.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole"
]
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.author"
}
]
},
{
"id": "EligibilityRequest.provider",
"path": "EligibilityRequest.provider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.requester"
},
{
"identity": "w5",
"map": "FiveWs.source"
}
]
},
{
"id": "EligibilityRequest.insurer",
"path": "EligibilityRequest.insurer",
"short": "Target",
"definition": "The Insurer who is target of the request.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.performer"
},
{
"identity": "w5",
"map": "FiveWs.who"
}
]
},
{
"id": "EligibilityRequest.facility",
"path": "EligibilityRequest.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.where[x]"
}
]
},
{
"id": "EligibilityRequest.coverage",
"path": "EligibilityRequest.coverage",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"comment": "1..1.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Coverage"
]
}
]
},
{
"id": "EligibilityRequest.businessArrangement",
"path": "EligibilityRequest.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EligibilityRequest.benefitCategory",
"path": "EligibilityRequest.benefitCategory",
"short": "Type of services covered",
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
}
],
"strength": "example",
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-category"
}
},
{
"id": "EligibilityRequest.benefitSubCategory",
"path": "EligibilityRequest.benefitSubCategory",
"short": "Detailed services covered within the type",
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
{
"id": "EligibilityRequest.authorization",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Authorization"
}
],
"path": "EligibilityRequest.authorization",
"short": "Services which may require prior authorization",
"definition": "A list of billable services for which an authorization prior to service delivery may be required by the payor.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "EligibilityRequest.authorization.sequence",
"path": "EligibilityRequest.authorization.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "EligibilityRequest.authorization.service",
"path": "EligibilityRequest.authorization.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id": "EligibilityRequest.authorization.modifier",
"path": "EligibilityRequest.authorization.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id": "EligibilityRequest.authorization.quantity",
"path": "EligibilityRequest.authorization.quantity",
"short": "Count of products or services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
]
},
{
"id": "EligibilityRequest.authorization.unitPrice",
"path": "EligibilityRequest.authorization.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "EligibilityRequest.authorization.facility",
"path": "EligibilityRequest.authorization.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location",
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
]
},
{
"id": "EligibilityRequest.authorization.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "0;115"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "EligibilityRequest.authorization.diagnosis",
"short": "List of Diagnosis",
"definition": "List of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"mapping": [
{
"identity": "v2",
"map": "Request.reasonReference"
}
]
},
{
"id": "EligibilityRequest.authorization.diagnosis.diagnosis[x]",
"path": "EligibilityRequest.authorization.diagnosis.diagnosis[x]",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Condition"
]
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
}
],
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
®© HL7.org 2011+. FHIR Mixed Nomative/Trial Use Ballot (v3.3.0-13671) generated on Tue, Apr 3, 2018 12:15+1000. QA Page
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