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

13.3 Resource CoverageEligibilityResponse - Content

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

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

13.3.1 Scope and Usage

The CoverageEligibilityResponse resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy benefit details as well as the ability for the insurer to indicate whether the insurance provides benefits for requested types of services or requires preauthorization and if so what supporting information may be required.

13.3.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse TUDomainResourceCoverageEligibilityResponse 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)
... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
EligibilityResponsePurpose (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates for inquiry
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... requestProvider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible provider
... request 0..1Reference(CoverageEligibilityRequest)Eligibility reference
... outcome 0..1codequeued | complete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer 0..1Reference(Organization)Insurer issuing the coverage
... insurance 0..*BackboneElementDetails by insurance coverage
.... coverage 0..1Reference(Coverage)Updated Coverage details
.... contract 0..1Reference(Contract)Contract details
.... inforce 0..1booleanCoverage inforce indicator
.... item I0..*BackboneElementBenefits and Authorization requirements by Category or Service
+ Rule: SHALL contain a category or a billcode but not both.
+ Rule: SHALL contain a billcode for modifier to be present.
..... 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)Performing practitioner
..... 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)
..... benefit 0..*BackboneElementBenefit Summary
...... type 1..1CodeableConceptDeductible, visits, benefit amount
Benefit Type Codes (Example)
...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedMoneyMoney
..... authorizationRequired 0..1booleanAuthorization required flag
..... authorizationSupporting 0..*CodeableConceptCodes or text of materials to be submitted
..... authorizationUrl 0..1uriPre-authorization requirements
... preAuthRef 0..1stringPre-Authorization/Determination Reference
... form 0..1CodeableConceptPrinted Form Identifier
Forms (Example)
... error 0..*BackboneElementProcessing errors
.... code 1..1CodeableConceptError code detailing processing issues
AdjudicationError (Example)

doco Documentation for this format

UML Diagram (Legend)

CoverageEligibilityResponse (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! »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)EligibilityResponsePurpose! »Patient Resourcepatient : Reference [0..1] « Patient »The date or dates when the enclosed suite of services are proposed and for which coverage details are requestedserviced[x] : Type [0..1] « date|Period »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The provider who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner|PractitionerRole| Organization »Original request resource referencerequest : Reference [0..1] « CoverageEligibilityRequest »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 »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 »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]ItemsHigh-level Dental, Vision, Medical, Pharmacy, Rehab etc. and detailed types of services: 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 (eg. 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, 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 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 »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 excludes Ortho, Implants and Cosmetic services'description : string [0..1]Network designationnetwork : CodeableConcept [0..1] « Code to classify in or out of network services. (Strength=Example)NetworkTypeCodes?? »Unit designation: individual or familyunit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. (Strength=Example)BenefitTermCodes?? »A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service deliveryauthorizationRequired : boolean [0..1]Codes or comments regarding information or actions assciated with the pre-authorizationauthorizationSupporting : CodeableConcept [0..*]A descriptive document locationauthorizationUrl : uri [0..1]BenefitDeductible, visits, benefit amounttype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)BenefitTypeCodes?? »Benefits allowedallowed[x] : Type [0..1] « unsignedInt|string|Money »Benefits usedused[x] : Type [0..1] « unsignedInt|Money »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 datebenefit[0..*]Benefits and optionally current balances by Category or Serviceitem[0..*]The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurerinsurance[0..*]Mutually exclusive with Services Provided (Item)error[0..*]

XML Template

<CoverageEligibilityResponse 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 -->
 <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 for inquiry --></serviced[x]>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible provider --></requestProvider>
 <request><!-- 0..1 Reference(CoverageEligibilityRequest) Eligibility reference --></request>
 <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 0..1 Reference(Organization) Insurer issuing the coverage --></insurer>
 <insurance>  <!-- 0..* Details by insurance coverage -->
  <coverage><!-- 0..1 Reference(Coverage) Updated Coverage details --></coverage>
  <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
  <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
  <item>  <!-- 0..* Benefits and Authorization requirements by Category or Service -->
   <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) Performing practitioner --></provider>
   <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>
   <benefit>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Deductible, 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]>
   </benefit>
   <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag -->
   <authorizationSupporting><!-- 0..* CodeableConcept Codes or text of materials to be submitted --></authorizationSupporting>
   <authorizationUrl value="[uri]"/><!-- 0..1 Pre-authorization requirements -->
  </item>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference -->
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</CoverageEligibilityResponse>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityResponse",
  // 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
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  // serviced[x]: Estimated date or dates for inquiry. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // Creation date
  "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible provider
  "request" : { Reference(CoverageEligibilityRequest) }, // Eligibility reference
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer issuing the coverage
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "inforce" : <boolean>, // Coverage inforce indicator
    "item" : [{ // Benefits and Authorization requirements by Category or Service
      "category" : { CodeableConcept }, // Type of service
      "billcode" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner
      "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
      "benefit" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Deductible, 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 }
      }],
      "authorizationRequired" : <boolean>, // Authorization required flag
      "authorizationSupporting" : [{ CodeableConcept }], // Codes or text of materials to be submitted
      "authorizationUrl" : "<uri>" // Pre-authorization requirements
    }]
  }],
  "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference
  "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:CoverageEligibilityResponse;
  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:CoverageEligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:CoverageEligibilityResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityResponse.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # CoverageEligibilityResponse.serviced[x] : 0..1 Estimated date or dates for inquiry. One of these 2
    fhir:CoverageEligibilityResponse.servicedDate [ date ]
    fhir:CoverageEligibilityResponse.servicedPeriod [ Period ]
  fhir:CoverageEligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:CoverageEligibilityResponse.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible provider
  fhir:CoverageEligibilityResponse.request [ Reference(CoverageEligibilityRequest) ]; # 0..1 Eligibility reference
  fhir:CoverageEligibilityResponse.outcome [ code ]; # 0..1 queued | complete | error | partial
  fhir:CoverageEligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:CoverageEligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer issuing the coverage
  fhir:CoverageEligibilityResponse.insurance [ # 0..* Details by insurance coverage
    fhir:CoverageEligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 0..1 Updated Coverage details
    fhir:CoverageEligibilityResponse.insurance.contract [ Reference(Contract) ]; # 0..1 Contract details
    fhir:CoverageEligibilityResponse.insurance.inforce [ boolean ]; # 0..1 Coverage inforce indicator
    fhir:CoverageEligibilityResponse.insurance.item [ # 0..* Benefits and Authorization requirements by Category or Service
      fhir:CoverageEligibilityResponse.insurance.item.category [ CodeableConcept ]; # 0..1 Type of service
      fhir:CoverageEligibilityResponse.insurance.item.billcode [ CodeableConcept ]; # 0..1 Billing Code
      fhir:CoverageEligibilityResponse.insurance.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:CoverageEligibilityResponse.insurance.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Performing practitioner
      fhir:CoverageEligibilityResponse.insurance.item.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:CoverageEligibilityResponse.insurance.item.name [ string ]; # 0..1 Short name for the benefit
      fhir:CoverageEligibilityResponse.insurance.item.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:CoverageEligibilityResponse.insurance.item.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:CoverageEligibilityResponse.insurance.item.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:CoverageEligibilityResponse.insurance.item.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:CoverageEligibilityResponse.insurance.item.benefit [ # 0..* Benefit Summary
        fhir:CoverageEligibilityResponse.insurance.item.benefit.type [ CodeableConcept ]; # 1..1 Deductible, visits, benefit amount
        # CoverageEligibilityResponse.insurance.item.benefit.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedMoney [ Money ]
        # CoverageEligibilityResponse.insurance.item.benefit.used[x] : 0..1 Benefits used. One of these 2
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedMoney [ Money ]
      ], ...;
      fhir:CoverageEligibilityResponse.insurance.item.authorizationRequired [ boolean ]; # 0..1 Authorization required flag
      fhir:CoverageEligibilityResponse.insurance.item.authorizationSupporting [ CodeableConcept ], ... ; # 0..* Codes or text of materials to be submitted
      fhir:CoverageEligibilityResponse.insurance.item.authorizationUrl [ uri ]; # 0..1 Pre-authorization requirements
    ], ...;
  ], ...;
  fhir:CoverageEligibilityResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference
  fhir:CoverageEligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:CoverageEligibilityResponse.error [ # 0..* Processing errors
    fhir:CoverageEligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since R3

This resource did not exist in Release 2

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse TUDomainResourceCoverageEligibilityResponse 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)
... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
EligibilityResponsePurpose (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates for inquiry
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... requestProvider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible provider
... request 0..1Reference(CoverageEligibilityRequest)Eligibility reference
... outcome 0..1codequeued | complete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer 0..1Reference(Organization)Insurer issuing the coverage
... insurance 0..*BackboneElementDetails by insurance coverage
.... coverage 0..1Reference(Coverage)Updated Coverage details
.... contract 0..1Reference(Contract)Contract details
.... inforce 0..1booleanCoverage inforce indicator
.... item I0..*BackboneElementBenefits and Authorization requirements by Category or Service
+ Rule: SHALL contain a category or a billcode but not both.
+ Rule: SHALL contain a billcode for modifier to be present.
..... 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)Performing practitioner
..... 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)
..... benefit 0..*BackboneElementBenefit Summary
...... type 1..1CodeableConceptDeductible, visits, benefit amount
Benefit Type Codes (Example)
...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedMoneyMoney
..... authorizationRequired 0..1booleanAuthorization required flag
..... authorizationSupporting 0..*CodeableConceptCodes or text of materials to be submitted
..... authorizationUrl 0..1uriPre-authorization requirements
... preAuthRef 0..1stringPre-Authorization/Determination Reference
... form 0..1CodeableConceptPrinted Form Identifier
Forms (Example)
... error 0..*BackboneElementProcessing errors
.... code 1..1CodeableConceptError code detailing processing issues
AdjudicationError (Example)

doco Documentation for this format

UML Diagram (Legend)

CoverageEligibilityResponse (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! »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)EligibilityResponsePurpose! »Patient Resourcepatient : Reference [0..1] « Patient »The date or dates when the enclosed suite of services are proposed and for which coverage details are requestedserviced[x] : Type [0..1] « date|Period »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The provider who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner|PractitionerRole| Organization »Original request resource referencerequest : Reference [0..1] « CoverageEligibilityRequest »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 »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 »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]ItemsHigh-level Dental, Vision, Medical, Pharmacy, Rehab etc. and detailed types of services: 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 (eg. 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, 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 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 »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 excludes Ortho, Implants and Cosmetic services'description : string [0..1]Network designationnetwork : CodeableConcept [0..1] « Code to classify in or out of network services. (Strength=Example)NetworkTypeCodes?? »Unit designation: individual or familyunit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. (Strength=Example)BenefitTermCodes?? »A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service deliveryauthorizationRequired : boolean [0..1]Codes or comments regarding information or actions assciated with the pre-authorizationauthorizationSupporting : CodeableConcept [0..*]A descriptive document locationauthorizationUrl : uri [0..1]BenefitDeductible, visits, benefit amounttype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)BenefitTypeCodes?? »Benefits allowedallowed[x] : Type [0..1] « unsignedInt|string|Money »Benefits usedused[x] : Type [0..1] « unsignedInt|Money »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 datebenefit[0..*]Benefits and optionally current balances by Category or Serviceitem[0..*]The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurerinsurance[0..*]Mutually exclusive with Services Provided (Item)error[0..*]

XML Template

<CoverageEligibilityResponse 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 -->
 <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 for inquiry --></serviced[x]>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible provider --></requestProvider>
 <request><!-- 0..1 Reference(CoverageEligibilityRequest) Eligibility reference --></request>
 <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 0..1 Reference(Organization) Insurer issuing the coverage --></insurer>
 <insurance>  <!-- 0..* Details by insurance coverage -->
  <coverage><!-- 0..1 Reference(Coverage) Updated Coverage details --></coverage>
  <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
  <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
  <item>  <!-- 0..* Benefits and Authorization requirements by Category or Service -->
   <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) Performing practitioner --></provider>
   <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>
   <benefit>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Deductible, 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]>
   </benefit>
   <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag -->
   <authorizationSupporting><!-- 0..* CodeableConcept Codes or text of materials to be submitted --></authorizationSupporting>
   <authorizationUrl value="[uri]"/><!-- 0..1 Pre-authorization requirements -->
  </item>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference -->
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</CoverageEligibilityResponse>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityResponse",
  // 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
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  // serviced[x]: Estimated date or dates for inquiry. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // Creation date
  "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible provider
  "request" : { Reference(CoverageEligibilityRequest) }, // Eligibility reference
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer issuing the coverage
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "inforce" : <boolean>, // Coverage inforce indicator
    "item" : [{ // Benefits and Authorization requirements by Category or Service
      "category" : { CodeableConcept }, // Type of service
      "billcode" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner
      "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
      "benefit" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Deductible, 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 }
      }],
      "authorizationRequired" : <boolean>, // Authorization required flag
      "authorizationSupporting" : [{ CodeableConcept }], // Codes or text of materials to be submitted
      "authorizationUrl" : "<uri>" // Pre-authorization requirements
    }]
  }],
  "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference
  "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:CoverageEligibilityResponse;
  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:CoverageEligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:CoverageEligibilityResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityResponse.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # CoverageEligibilityResponse.serviced[x] : 0..1 Estimated date or dates for inquiry. One of these 2
    fhir:CoverageEligibilityResponse.servicedDate [ date ]
    fhir:CoverageEligibilityResponse.servicedPeriod [ Period ]
  fhir:CoverageEligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:CoverageEligibilityResponse.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible provider
  fhir:CoverageEligibilityResponse.request [ Reference(CoverageEligibilityRequest) ]; # 0..1 Eligibility reference
  fhir:CoverageEligibilityResponse.outcome [ code ]; # 0..1 queued | complete | error | partial
  fhir:CoverageEligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:CoverageEligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer issuing the coverage
  fhir:CoverageEligibilityResponse.insurance [ # 0..* Details by insurance coverage
    fhir:CoverageEligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 0..1 Updated Coverage details
    fhir:CoverageEligibilityResponse.insurance.contract [ Reference(Contract) ]; # 0..1 Contract details
    fhir:CoverageEligibilityResponse.insurance.inforce [ boolean ]; # 0..1 Coverage inforce indicator
    fhir:CoverageEligibilityResponse.insurance.item [ # 0..* Benefits and Authorization requirements by Category or Service
      fhir:CoverageEligibilityResponse.insurance.item.category [ CodeableConcept ]; # 0..1 Type of service
      fhir:CoverageEligibilityResponse.insurance.item.billcode [ CodeableConcept ]; # 0..1 Billing Code
      fhir:CoverageEligibilityResponse.insurance.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:CoverageEligibilityResponse.insurance.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Performing practitioner
      fhir:CoverageEligibilityResponse.insurance.item.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:CoverageEligibilityResponse.insurance.item.name [ string ]; # 0..1 Short name for the benefit
      fhir:CoverageEligibilityResponse.insurance.item.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:CoverageEligibilityResponse.insurance.item.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:CoverageEligibilityResponse.insurance.item.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:CoverageEligibilityResponse.insurance.item.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:CoverageEligibilityResponse.insurance.item.benefit [ # 0..* Benefit Summary
        fhir:CoverageEligibilityResponse.insurance.item.benefit.type [ CodeableConcept ]; # 1..1 Deductible, visits, benefit amount
        # CoverageEligibilityResponse.insurance.item.benefit.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedMoney [ Money ]
        # CoverageEligibilityResponse.insurance.item.benefit.used[x] : 0..1 Benefits used. One of these 2
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedMoney [ Money ]
      ], ...;
      fhir:CoverageEligibilityResponse.insurance.item.authorizationRequired [ boolean ]; # 0..1 Authorization required flag
      fhir:CoverageEligibilityResponse.insurance.item.authorizationSupporting [ CodeableConcept ], ... ; # 0..* Codes or text of materials to be submitted
      fhir:CoverageEligibilityResponse.insurance.item.authorizationUrl [ uri ]; # 0..1 Pre-authorization requirements
    ], ...;
  ], ...;
  fhir:CoverageEligibilityResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference
  fhir:CoverageEligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:CoverageEligibilityResponse.error [ # 0..* Processing errors
    fhir:CoverageEligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

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

13.3.2.1 Terminology Bindings

PathDefinitionTypeReference
CoverageEligibilityResponse.status A code specifying the state of the resource instance.RequiredFinancialResourceStatusCodes
CoverageEligibilityResponse.purpose A code specifying the types of information being requested.RequiredEligibilityResponsePurpose
CoverageEligibilityResponse.outcome The outcome of the processing.RequiredRemittanceOutcome
CoverageEligibilityResponse.insurance.item.category Benefit categories such as: oral, medical, vision etc.ExampleBenefitCategoryCodes
CoverageEligibilityResponse.insurance.item.billcode Allowable service and product codes.ExampleUSCLSCodes
CoverageEligibilityResponse.insurance.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
CoverageEligibilityResponse.insurance.item.network Code to classify in or out of network services.ExampleNetworkTypeCodes
CoverageEligibilityResponse.insurance.item.unit Unit covered/serviced - individual or family.ExampleUnitTypeCodes
CoverageEligibilityResponse.insurance.item.term Coverage unit - annual, lifetime.ExampleBenefitTermCodes
CoverageEligibilityResponse.insurance.item.benefit.type Deductable, visits, co-pay, etc.ExampleBenefitTypeCodes
CoverageEligibilityResponse.form The forms codes.ExampleForm Codes
CoverageEligibilityResponse.error.code The error codes for adjudication processing.ExampleAdjudication Error Codes

13.3.2.2 Constraints

idLevelLocationDescriptionExpression
ces-1Rule CoverageEligibilityResponse.insurance.itemSHALL contain a category or a billcode but not both.category.exists() xor billcode.exists()
ces-2Rule CoverageEligibilityResponse.insurance.itemSHALL contain a billcode for modifier to be present.modifier.exists() and billcode.exists()

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 dateCoverageEligibilityResponse.created
dispositionstringThe contents of the disposition messageCoverageEligibilityResponse.disposition
identifiertokenThe business identifierCoverageEligibilityResponse.identifier
insurerreferenceThe organization which generated this resourceCoverageEligibilityResponse.insurer
(Organization)
outcometokenThe processing outcomeCoverageEligibilityResponse.outcome
patientreferenceThe reference to the patientCoverageEligibilityResponse.patient
(Patient)
requestreferenceThe EligibilityRequest referenceCoverageEligibilityResponse.request
(CoverageEligibilityRequest)
request-providerreferenceThe EligibilityRequest providerCoverageEligibilityResponse.requestProvider
(Practitioner, Organization, PractitionerRole)
statustokenThe EligibilityRequest statusCoverageEligibilityResponse.status