The CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.

The Response business identifier.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the request as not currently valid.

Immediate (STAT), best effort (NORMAL), deferred (DEFER).

Specify whether requesting: prior authorization requirements for some service categories or billing codes; benefits for coverages specified or discovered; discovery and return of coverages for th patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.

Patient Resource.

1..1.

The date or dates when the enclosed suite of services were performed or completed.

The date when this resource was created.

Person who created the invoice/claim/pre-determination or pre-authorization.

The provider who is responsible for the services rendered to the patient.

The Insurer who is target of the request.

Facility where the services were provided.

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Sequence of the information element which serves to provide a link.

To provide a reference link.

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

The supporting materials are applicable for all detail intens, product/servce categories and specific billing codes.

Insurance policies which the patient has advised may be applicable for paying for health services.

A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

To identify which coverage is being adjudicated.

Financial instrument by which payment information for health care.

Need to identify the issuer to target for processing and for coordination of benefit processing.

The contract number of a business agreement which describes the terms and conditions.

A list of service types or billable services for which bebefit details and/or an authorization prior to service delivery may be required by the payor.

Exceptions, special conditions and supporting information pplicable for this service or product line.

Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.

A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).

Item typification or modifiers codes, e.g. 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.

The practitioner who is responsible for the services rendered to the patient.

The number of repetitions of a service or product.

The fee for an additional service or product or charge.

Facility where the services were provided.

List of patient diagnosis for which care is sought.

The diagnosis.

Required to adjudicate services rendered to condition presented.

The plan/proposal/order describing the proposed service in detail.

Need to identify the issuer to target for processing and for coordination of benefit processing.