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

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 response as not currently valid.

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.

The date or dates when the enclosed suite of services are proposed and for which coverage details are requested.

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

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

Original request resource reference.

Transaction status: error, complete.

A description of the status of the adjudication.

The Insurer who produced this adjudicated response.

The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer.

A suite of updated or additional Coverages from the Insurer.

The contract resource which may provide more detailed information.

Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.

Benefits and optionally current balances by Category or Service.

High-level Dental, Vision, Medical, Pharmacy, Rehab etc. and detailed types of services: Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.

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

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.

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

True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.

A short name or tag for the benefit, for example MED01, or DENT2.

A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

Network designation.

Unit designation: individual or family.

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Benefits used to date.

Deductible, visits, benefit amount.

Benefits allowed.

Benefits used.

A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service delivery.

Codes or comments regarding information or actions assciated with the pre-authorization.

A descriptive document location.

A reference from the Insurer to which these services pertain.

To provide any pre-determination or prior authorization reference.

The form to be used for printing the content.

Mutually exclusive with Services Provided (Item).

An error code,from a specified code system, which details why the eligibility check could not be performed.