R4 Ballot #2 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.5.0: 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: R5 R4B R4

13.2 Resource CoverageEligibilityRequest - Content

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

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.

13.2.1 Scope and Usage

The CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding: (validation) whether the specified coverage(s) is valid and in-force; (discovery) what coverages the insurer has for the specified patient; (benefits) the benefits provided under the coverage; whether benefits exist under the specified coverage(s) for specified classes of services and products; and (auth-requirements) whether preauthorization is required, and if so what information may be required in that preauthorization, for the specified service classes or services.

This resource is referenced by CoverageEligibilityResponse

13.2.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityRequest TUDomainResourceCoverageEligibilityRequest 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)
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
EligibilityRequestPurpose (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible provider
... insurer 0..1Reference(Organization)Target
... facility 0..1Reference(Location)Servicing Facility
... supportingInformation 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1positiveIntInformation instance identifier
.... information 1..1Reference(Any)Additional Data or supporting information
.... appliesToAll 0..1booleanApplies to all items
... insurance 0..*BackboneElementPatient's Insurance or medical plan(s)
.... focal 0..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance or medical plan
.... businessArrangement 0..1stringBusiness agreement
... item 0..*BackboneElementService types, codes and supporting information
.... supportingInformationSequence 0..*positiveIntApplicable exception and supporting information
.... category 0..1CodeableConceptType of service
Benefit Category Codes (Example)
.... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... provider 0..1Reference(Practitioner | PractitionerRole)Perfoming practitioner
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... facility 0..1Reference(Location | Organization)Servicing Facility
.... diagnosis 0..*BackboneElementList of Diagnosis
..... diagnosis[x] 0..1Patient's diagnosis
ICD-10 Codes (Example)
...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)
.... detail 0..*Reference(Any)Product or service details

doco Documentation for this format

UML Diagram (Legend)

CoverageEligibilityRequest (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)FinancialResourceStatusCodes! »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example)ProcessPriorityCodes?? »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 specifiedpurpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required)EligibilityRequestPurpose! »Patient Resourcepatient : Reference [0..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The provider who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »Facility where the services were providedfacility : Reference [0..1] « Location »InformationSequence of the information element which serves to provide a linksequence : positiveInt [1..1]Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datainformation : Reference [1..1] « Any »The supporting materials are applicable for all detail intens, product/servce categories and specific billing codesappliesToAll : boolean [0..1]InsuranceA flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [0..1]Financial instrument by which payment information for health carecoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]DetailsExceptions, special conditions and supporting information pplicable for this service or product linesupportingInformationSequence : positiveInt [0..*]Dental: basic, major, ortho; Vision exam, glasses, contacts; etccategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)BenefitCategoryCodes?? »A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner|PractitionerRole »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an additional service or product or chargeunitPrice : Money [0..1]Facility where the services were providedfacility : Reference [0..1] « Location|Organization »The plan/proposal/order describing the proposed service in detaildetail : Reference [0..*] « Any »DiagnosisThe diagnosisdiagnosis[x] : Type [0..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are requiredsupportingInformation[0..*]Insurance policies which the patient has advised may be applicable for paying for health servicesinsurance[0..*]List of patient diagnosis for which care is soughtdiagnosis[0..*]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 payoritem[0..*]

XML Template

<CoverageEligibilityRequest 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 -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation -->
 <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|PractitionerRole) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible provider --></provider>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <supportingInformation>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <information><!-- 1..1 Reference(Any) Additional Data or supporting information --></information>
  <appliesToAll value="[boolean]"/><!-- 0..1 Applies to all items -->
 </supportingInformation>
 <insurance>  <!-- 0..* Patient's Insurance or medical plan(s) -->
  <focal value="[boolean]"/><!-- 0..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance or medical plan --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 </insurance>
 <item>  <!-- 0..* Service types, codes and supporting information -->
  <supportingInformationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <category><!-- 0..1 CodeableConcept Type of service --></category>
  <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Perfoming practitioner --></provider>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>
  <diagnosis>  <!-- 0..* List of Diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  </diagnosis>
  <detail><!-- 0..* Reference(Any) Product or service details --></detail>
 </item>
</CoverageEligibilityRequest>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityRequest",
  // 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
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "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|PractitionerRole) }, // Author
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible provider
  "insurer" : { Reference(Organization) }, // Target
  "facility" : { Reference(Location) }, // Servicing Facility
  "supportingInformation" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "information" : { Reference(Any) }, // R!  Additional Data or supporting information
    "appliesToAll" : <boolean> // Applies to all items
  }],
  "insurance" : [{ // Patient's Insurance or medical plan(s)
    "focal" : <boolean>, // Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance or medical plan
    "businessArrangement" : "<string>" // Business agreement
  }],
  "item" : [{ // Service types, codes and supporting information
    "supportingInformationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "category" : { CodeableConcept }, // Type of service
    "billcode" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "provider" : { Reference(Practitioner|PractitionerRole) }, // Perfoming practitioner
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "facility" : { Reference(Location|Organization) }, // Servicing Facility
    "diagnosis" : [{ // List of Diagnosis
      // diagnosis[x]: Patient's diagnosis. One of these 2:
      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }],
    "detail" : [{ Reference(Any) }] // Product or service details
  }]
}

Turtle Template

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


[ a fhir:CoverageEligibilityRequest;
  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:CoverageEligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:CoverageEligibilityRequest.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:CoverageEligibilityRequest.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # CoverageEligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2
    fhir:CoverageEligibilityRequest.servicedDate [ date ]
    fhir:CoverageEligibilityRequest.servicedPeriod [ Period ]
  fhir:CoverageEligibilityRequest.created [ dateTime ]; # 0..1 Creation date
  fhir:CoverageEligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:CoverageEligibilityRequest.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible provider
  fhir:CoverageEligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:CoverageEligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:CoverageEligibilityRequest.supportingInformation [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:CoverageEligibilityRequest.supportingInformation.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:CoverageEligibilityRequest.supportingInformation.information [ Reference(Any) ]; # 1..1 Additional Data or supporting information
    fhir:CoverageEligibilityRequest.supportingInformation.appliesToAll [ boolean ]; # 0..1 Applies to all items
  ], ...;
  fhir:CoverageEligibilityRequest.insurance [ # 0..* Patient's Insurance or medical plan(s)
    fhir:CoverageEligibilityRequest.insurance.focal [ boolean ]; # 0..1 Is the focal Coverage
    fhir:CoverageEligibilityRequest.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance or medical plan
    fhir:CoverageEligibilityRequest.insurance.businessArrangement [ string ]; # 0..1 Business agreement
  ], ...;
  fhir:CoverageEligibilityRequest.item [ # 0..* Service types, codes and supporting information
    fhir:CoverageEligibilityRequest.item.supportingInformationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:CoverageEligibilityRequest.item.category [ CodeableConcept ]; # 0..1 Type of service
    fhir:CoverageEligibilityRequest.item.billcode [ CodeableConcept ]; # 0..1 Billing Code
    fhir:CoverageEligibilityRequest.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:CoverageEligibilityRequest.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Perfoming practitioner
    fhir:CoverageEligibilityRequest.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:CoverageEligibilityRequest.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:CoverageEligibilityRequest.item.facility [ Reference(Location|Organization) ]; # 0..1 Servicing Facility
    fhir:CoverageEligibilityRequest.item.diagnosis [ # 0..* List of Diagnosis
      # CoverageEligibilityRequest.item.diagnosis.diagnosis[x] : 0..1 Patient's diagnosis. One of these 2
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
    fhir:CoverageEligibilityRequest.item.detail [ Reference(Any) ], ... ; # 0..* Product or service details
  ], ...;
]

Changes since R3

This resource did not exist in Release 2

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityRequest TUDomainResourceCoverageEligibilityRequest 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)
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
EligibilityRequestPurpose (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible provider
... insurer 0..1Reference(Organization)Target
... facility 0..1Reference(Location)Servicing Facility
... supportingInformation 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1positiveIntInformation instance identifier
.... information 1..1Reference(Any)Additional Data or supporting information
.... appliesToAll 0..1booleanApplies to all items
... insurance 0..*BackboneElementPatient's Insurance or medical plan(s)
.... focal 0..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance or medical plan
.... businessArrangement 0..1stringBusiness agreement
... item 0..*BackboneElementService types, codes and supporting information
.... supportingInformationSequence 0..*positiveIntApplicable exception and supporting information
.... category 0..1CodeableConceptType of service
Benefit Category Codes (Example)
.... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... provider 0..1Reference(Practitioner | PractitionerRole)Perfoming practitioner
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... facility 0..1Reference(Location | Organization)Servicing Facility
.... diagnosis 0..*BackboneElementList of Diagnosis
..... diagnosis[x] 0..1Patient's diagnosis
ICD-10 Codes (Example)
...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)
.... detail 0..*Reference(Any)Product or service details

doco Documentation for this format

UML Diagram (Legend)

CoverageEligibilityRequest (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)FinancialResourceStatusCodes! »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example)ProcessPriorityCodes?? »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 specifiedpurpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required)EligibilityRequestPurpose! »Patient Resourcepatient : Reference [0..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The provider who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »Facility where the services were providedfacility : Reference [0..1] « Location »InformationSequence of the information element which serves to provide a linksequence : positiveInt [1..1]Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datainformation : Reference [1..1] « Any »The supporting materials are applicable for all detail intens, product/servce categories and specific billing codesappliesToAll : boolean [0..1]InsuranceA flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [0..1]Financial instrument by which payment information for health carecoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]DetailsExceptions, special conditions and supporting information pplicable for this service or product linesupportingInformationSequence : positiveInt [0..*]Dental: basic, major, ortho; Vision exam, glasses, contacts; etccategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)BenefitCategoryCodes?? »A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner|PractitionerRole »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an additional service or product or chargeunitPrice : Money [0..1]Facility where the services were providedfacility : Reference [0..1] « Location|Organization »The plan/proposal/order describing the proposed service in detaildetail : Reference [0..*] « Any »DiagnosisThe diagnosisdiagnosis[x] : Type [0..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are requiredsupportingInformation[0..*]Insurance policies which the patient has advised may be applicable for paying for health servicesinsurance[0..*]List of patient diagnosis for which care is soughtdiagnosis[0..*]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 payoritem[0..*]

XML Template

<CoverageEligibilityRequest 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 -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation -->
 <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|PractitionerRole) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible provider --></provider>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <supportingInformation>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <information><!-- 1..1 Reference(Any) Additional Data or supporting information --></information>
  <appliesToAll value="[boolean]"/><!-- 0..1 Applies to all items -->
 </supportingInformation>
 <insurance>  <!-- 0..* Patient's Insurance or medical plan(s) -->
  <focal value="[boolean]"/><!-- 0..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance or medical plan --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 </insurance>
 <item>  <!-- 0..* Service types, codes and supporting information -->
  <supportingInformationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <category><!-- 0..1 CodeableConcept Type of service --></category>
  <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Perfoming practitioner --></provider>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>
  <diagnosis>  <!-- 0..* List of Diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  </diagnosis>
  <detail><!-- 0..* Reference(Any) Product or service details --></detail>
 </item>
</CoverageEligibilityRequest>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityRequest",
  // 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
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "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|PractitionerRole) }, // Author
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible provider
  "insurer" : { Reference(Organization) }, // Target
  "facility" : { Reference(Location) }, // Servicing Facility
  "supportingInformation" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "information" : { Reference(Any) }, // R!  Additional Data or supporting information
    "appliesToAll" : <boolean> // Applies to all items
  }],
  "insurance" : [{ // Patient's Insurance or medical plan(s)
    "focal" : <boolean>, // Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance or medical plan
    "businessArrangement" : "<string>" // Business agreement
  }],
  "item" : [{ // Service types, codes and supporting information
    "supportingInformationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "category" : { CodeableConcept }, // Type of service
    "billcode" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "provider" : { Reference(Practitioner|PractitionerRole) }, // Perfoming practitioner
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "facility" : { Reference(Location|Organization) }, // Servicing Facility
    "diagnosis" : [{ // List of Diagnosis
      // diagnosis[x]: Patient's diagnosis. One of these 2:
      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }],
    "detail" : [{ Reference(Any) }] // Product or service details
  }]
}

Turtle Template

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


[ a fhir:CoverageEligibilityRequest;
  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:CoverageEligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:CoverageEligibilityRequest.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:CoverageEligibilityRequest.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # CoverageEligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2
    fhir:CoverageEligibilityRequest.servicedDate [ date ]
    fhir:CoverageEligibilityRequest.servicedPeriod [ Period ]
  fhir:CoverageEligibilityRequest.created [ dateTime ]; # 0..1 Creation date
  fhir:CoverageEligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:CoverageEligibilityRequest.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible provider
  fhir:CoverageEligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:CoverageEligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:CoverageEligibilityRequest.supportingInformation [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:CoverageEligibilityRequest.supportingInformation.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:CoverageEligibilityRequest.supportingInformation.information [ Reference(Any) ]; # 1..1 Additional Data or supporting information
    fhir:CoverageEligibilityRequest.supportingInformation.appliesToAll [ boolean ]; # 0..1 Applies to all items
  ], ...;
  fhir:CoverageEligibilityRequest.insurance [ # 0..* Patient's Insurance or medical plan(s)
    fhir:CoverageEligibilityRequest.insurance.focal [ boolean ]; # 0..1 Is the focal Coverage
    fhir:CoverageEligibilityRequest.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance or medical plan
    fhir:CoverageEligibilityRequest.insurance.businessArrangement [ string ]; # 0..1 Business agreement
  ], ...;
  fhir:CoverageEligibilityRequest.item [ # 0..* Service types, codes and supporting information
    fhir:CoverageEligibilityRequest.item.supportingInformationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:CoverageEligibilityRequest.item.category [ CodeableConcept ]; # 0..1 Type of service
    fhir:CoverageEligibilityRequest.item.billcode [ CodeableConcept ]; # 0..1 Billing Code
    fhir:CoverageEligibilityRequest.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:CoverageEligibilityRequest.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Perfoming practitioner
    fhir:CoverageEligibilityRequest.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:CoverageEligibilityRequest.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:CoverageEligibilityRequest.item.facility [ Reference(Location|Organization) ]; # 0..1 Servicing Facility
    fhir:CoverageEligibilityRequest.item.diagnosis [ # 0..* List of Diagnosis
      # CoverageEligibilityRequest.item.diagnosis.diagnosis[x] : 0..1 Patient's diagnosis. One of these 2
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
    fhir:CoverageEligibilityRequest.item.detail [ Reference(Any) ], ... ; # 0..* Product or service details
  ], ...;
]

Changes since Release 3

This resource did not exist in Release 2

This analysis is available as XML or JSON.

 

See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

13.2.2.1 Terminology Bindings

PathDefinitionTypeReference
CoverageEligibilityRequest.status A code specifying the state of the resource instance.RequiredFinancialResourceStatusCodes
CoverageEligibilityRequest.priority The timeliness with which processing is required: STAT, normal, Deferred.ExampleProcessPriorityCodes
CoverageEligibilityRequest.purpose A code specifying the types of information being requested.RequiredEligibilityRequestPurpose
CoverageEligibilityRequest.item.category Benefit categories such as: oral, medical, vision etc.ExampleBenefitCategoryCodes
CoverageEligibilityRequest.item.billcode Allowable service and product codes.ExampleUSCLSCodes
CoverageEligibilityRequest.item.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.ExampleModifierTypeCodes
CoverageEligibilityRequest.item.diagnosis.diagnosis[x] ICD10 Diagnostic codes.ExampleICD-10Codes

13.2.3 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 date for the EOBCoverageEligibilityRequest.created
entererreferenceThe party who is responsible for the requestCoverageEligibilityRequest.enterer
(Practitioner, PractitionerRole)
facilityreferenceFacility responsible for the goods and servicesCoverageEligibilityRequest.facility
(Location)
identifiertokenThe business identifier of the EligibilityCoverageEligibilityRequest.identifier
patientreferenceThe reference to the patientCoverageEligibilityRequest.patient
(Patient)
providerreferenceThe reference to the providerCoverageEligibilityRequest.provider
(Practitioner, Organization, PractitionerRole)
statustokenThe status of the EligibilityRequestCoverageEligibilityRequest.status