This page is part of the FHIR Specification (v4.4.0: R5 Preview #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
Financial Management Work Group | Maturity Level: 2 | Trial Use | Security Category: Patient | 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.
The CoverageEligibilityRequest makes a request of an insurer asking them to provide, in the form of an CoverageEligibilityResponse, 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.
The CoverageEligibilityRequest resource is a "event" resource from a FHIR workflow perspective - see Workflow Event.
Additional information regarding electronic coverage eligibility content and usage may be found at:
CoverageEligibilityRequest should be used when requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage.
The Claim resource should be used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.
The Coverage resource contains the information typically found on the health insurance card for an individual used to identify the covered individual to the insurer and is referred to by the CoverageEligibilityRequest.
The eClaim domain includes a number of related resources
CoverageEligibilityRequest | Patient and insurance coverage information provided 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. |
Claim | A suite of goods and services and insurances coverages under which adjudication or authorization is requested. |
Coverage | Provides the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services. |
This resource is referenced by CoverageEligibilityResponse.
This resource implements the Request pattern.
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CoverageEligibilityRequest | TU | DomainResource | CoverageEligibilityRequest resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | 0..* | Identifier | Business Identifier for coverage eligiblity request | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Financial Resource Status Codes (Required) |
priority | 0..1 | CodeableConcept | Desired processing priority Process Priority Codes (Example) | |
purpose | Σ | 1..* | code | auth-requirements | benefits | discovery | validation EligibilityRequestPurpose (Required) |
patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services |
serviced[x] | 0..1 | Estimated date or dates of service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
created | Σ | 1..1 | dateTime | Creation date |
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author | |
provider | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |
insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer |
facility | 0..1 | Reference(Location) | Servicing facility | |
supportingInfo | 0..* | BackboneElement | Supporting information | |
sequence | 1..1 | positiveInt | Information instance identifier | |
information | 1..1 | Reference(Any) | Data to be provided | |
appliesToAll | 0..1 | boolean | Applies to all items | |
insurance | 0..* | BackboneElement | Patient insurance information | |
focal | 0..1 | boolean | Applicable coverage | |
coverage | 1..1 | Reference(Coverage) | Insurance information | |
businessArrangement | 0..1 | string | Additional provider contract number | |
item | 0..* | BackboneElement | Item to be evaluated for eligibiity | |
supportingInfoSequence | 0..* | positiveInt | Applicable exception or supporting information | |
category | 0..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | |
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Product or service billing modifiers Modifier type Codes (Example) | |
provider | 0..1 | Reference(Practitioner | PractitionerRole) | Perfoming practitioner | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
facility | 0..1 | Reference(Location | Organization) | Servicing facility | |
diagnosis | 0..* | BackboneElement | Applicable diagnosis | |
diagnosis[x] | 0..1 | Nature of illness or problem ICD-10 Codes (Example) | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(Condition) | |||
detail | 0..* | Reference(Any) | Product or service details | |
Documentation for this format |
UML Diagram (Legend)
XML Template
<CoverageEligibilityRequest xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier> <status value="[code]"/><!-- 1..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><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient> <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]> <created value="[dateTime]"/><!-- 1..1 Creation date --> <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer> <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></provider> <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer> <facility><!-- 0..1 Reference(Location) Servicing facility --></facility> <supportingInfo> <!-- 0..* Supporting information --> <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier --> <information><!-- 1..1 Reference(Any) Data to be provided --></information> <appliesToAll value="[boolean]"/><!-- 0..1 Applies to all items --> </supportingInfo> <insurance> <!-- 0..* Patient insurance information --> <focal value="[boolean]"/><!-- 0..1 Applicable coverage --> <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage> <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number --> </insurance> <item> <!-- 0..* Item to be evaluated for eligibiity --> <supportingInfoSequence value="[positiveInt]"/><!-- 0..* Applicable exception or supporting information --> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <modifier><!-- 0..* CodeableConcept Product or service 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 item --></unitPrice> <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility> <diagnosis> <!-- 0..* Applicable diagnosis --> <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]> </diagnosis> <detail><!-- 0..* Reference(Any) Product or service details --></detail> </item> </CoverageEligibilityRequest>
JSON Template
{ "resourceType" : "CoverageEligibilityRequest", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request "status" : "<code>", // R! active | cancelled | draft | entered-in-error "priority" : { CodeableConcept }, // Desired processing priority "purpose" : ["<code>"], // R! auth-requirements | benefits | discovery | validation "patient" : { Reference(Patient) }, // R! Intended recipient of products and services // serviced[x]: Estimated date or dates of service. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, "created" : "<dateTime>", // R! Creation date "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request "insurer" : { Reference(Organization) }, // R! Coverage issuer "facility" : { Reference(Location) }, // Servicing facility "supportingInfo" : [{ // Supporting information "sequence" : "<positiveInt>", // R! Information instance identifier "information" : { Reference(Any) }, // R! Data to be provided "appliesToAll" : <boolean> // Applies to all items }], "insurance" : [{ // Patient insurance information "focal" : <boolean>, // Applicable coverage "coverage" : { Reference(Coverage) }, // R! Insurance information "businessArrangement" : "<string>" // Additional provider contract number }], "item" : [{ // Item to be evaluated for eligibiity "supportingInfoSequence" : ["<positiveInt>"], // Applicable exception or supporting information "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "modifier" : [{ CodeableConcept }], // Product or service billing modifiers "provider" : { Reference(Practitioner|PractitionerRole) }, // Perfoming practitioner "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "facility" : { Reference(Location|Organization) }, // Servicing facility "diagnosis" : [{ // Applicable diagnosis // diagnosis[x]: Nature of illness or problem. One of these 2: "diagnosisCodeableConcept" : { CodeableConcept } "diagnosisReference" : { Reference(Condition) } }], "detail" : [{ Reference(Any) }] // Product or service details }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ 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 for coverage eligiblity request fhir:CoverageEligibilityRequest.status [ code ]; # 1..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) ]; # 1..1 Intended recipient of 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 ]; # 1..1 Creation date fhir:CoverageEligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author fhir:CoverageEligibilityRequest.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the request fhir:CoverageEligibilityRequest.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer fhir:CoverageEligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing facility fhir:CoverageEligibilityRequest.supportingInfo [ # 0..* Supporting information fhir:CoverageEligibilityRequest.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier fhir:CoverageEligibilityRequest.supportingInfo.information [ Reference(Any) ]; # 1..1 Data to be provided fhir:CoverageEligibilityRequest.supportingInfo.appliesToAll [ boolean ]; # 0..1 Applies to all items ], ...; fhir:CoverageEligibilityRequest.insurance [ # 0..* Patient insurance information fhir:CoverageEligibilityRequest.insurance.focal [ boolean ]; # 0..1 Applicable coverage fhir:CoverageEligibilityRequest.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information fhir:CoverageEligibilityRequest.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number ], ...; fhir:CoverageEligibilityRequest.item [ # 0..* Item to be evaluated for eligibiity fhir:CoverageEligibilityRequest.item.supportingInfoSequence [ positiveInt ], ... ; # 0..* Applicable exception or supporting information fhir:CoverageEligibilityRequest.item.category [ CodeableConcept ]; # 0..1 Benefit classification fhir:CoverageEligibilityRequest.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code fhir:CoverageEligibilityRequest.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service 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 item fhir:CoverageEligibilityRequest.item.facility [ Reference(Location|Organization) ]; # 0..1 Servicing facility fhir:CoverageEligibilityRequest.item.diagnosis [ # 0..* Applicable diagnosis # CoverageEligibilityRequest.item.diagnosis.diagnosis[x] : 0..1 Nature of illness or problem. 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
CoverageEligibilityRequest | |
CoverageEligibilityRequest.status |
|
CoverageEligibilityRequest.purpose |
|
See the Full Difference for further information
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CoverageEligibilityRequest | TU | DomainResource | CoverageEligibilityRequest resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | 0..* | Identifier | Business Identifier for coverage eligiblity request | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Financial Resource Status Codes (Required) |
priority | 0..1 | CodeableConcept | Desired processing priority Process Priority Codes (Example) | |
purpose | Σ | 1..* | code | auth-requirements | benefits | discovery | validation EligibilityRequestPurpose (Required) |
patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services |
serviced[x] | 0..1 | Estimated date or dates of service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
created | Σ | 1..1 | dateTime | Creation date |
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author | |
provider | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |
insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer |
facility | 0..1 | Reference(Location) | Servicing facility | |
supportingInfo | 0..* | BackboneElement | Supporting information | |
sequence | 1..1 | positiveInt | Information instance identifier | |
information | 1..1 | Reference(Any) | Data to be provided | |
appliesToAll | 0..1 | boolean | Applies to all items | |
insurance | 0..* | BackboneElement | Patient insurance information | |
focal | 0..1 | boolean | Applicable coverage | |
coverage | 1..1 | Reference(Coverage) | Insurance information | |
businessArrangement | 0..1 | string | Additional provider contract number | |
item | 0..* | BackboneElement | Item to be evaluated for eligibiity | |
supportingInfoSequence | 0..* | positiveInt | Applicable exception or supporting information | |
category | 0..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | |
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Product or service billing modifiers Modifier type Codes (Example) | |
provider | 0..1 | Reference(Practitioner | PractitionerRole) | Perfoming practitioner | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
facility | 0..1 | Reference(Location | Organization) | Servicing facility | |
diagnosis | 0..* | BackboneElement | Applicable diagnosis | |
diagnosis[x] | 0..1 | Nature of illness or problem ICD-10 Codes (Example) | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(Condition) | |||
detail | 0..* | Reference(Any) | Product or service details | |
Documentation for this format |
XML Template
<CoverageEligibilityRequest xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier> <status value="[code]"/><!-- 1..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><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient> <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]> <created value="[dateTime]"/><!-- 1..1 Creation date --> <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer> <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></provider> <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer> <facility><!-- 0..1 Reference(Location) Servicing facility --></facility> <supportingInfo> <!-- 0..* Supporting information --> <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier --> <information><!-- 1..1 Reference(Any) Data to be provided --></information> <appliesToAll value="[boolean]"/><!-- 0..1 Applies to all items --> </supportingInfo> <insurance> <!-- 0..* Patient insurance information --> <focal value="[boolean]"/><!-- 0..1 Applicable coverage --> <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage> <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number --> </insurance> <item> <!-- 0..* Item to be evaluated for eligibiity --> <supportingInfoSequence value="[positiveInt]"/><!-- 0..* Applicable exception or supporting information --> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <modifier><!-- 0..* CodeableConcept Product or service 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 item --></unitPrice> <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility> <diagnosis> <!-- 0..* Applicable diagnosis --> <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]> </diagnosis> <detail><!-- 0..* Reference(Any) Product or service details --></detail> </item> </CoverageEligibilityRequest>
JSON Template
{ "resourceType" : "CoverageEligibilityRequest", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request "status" : "<code>", // R! active | cancelled | draft | entered-in-error "priority" : { CodeableConcept }, // Desired processing priority "purpose" : ["<code>"], // R! auth-requirements | benefits | discovery | validation "patient" : { Reference(Patient) }, // R! Intended recipient of products and services // serviced[x]: Estimated date or dates of service. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, "created" : "<dateTime>", // R! Creation date "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request "insurer" : { Reference(Organization) }, // R! Coverage issuer "facility" : { Reference(Location) }, // Servicing facility "supportingInfo" : [{ // Supporting information "sequence" : "<positiveInt>", // R! Information instance identifier "information" : { Reference(Any) }, // R! Data to be provided "appliesToAll" : <boolean> // Applies to all items }], "insurance" : [{ // Patient insurance information "focal" : <boolean>, // Applicable coverage "coverage" : { Reference(Coverage) }, // R! Insurance information "businessArrangement" : "<string>" // Additional provider contract number }], "item" : [{ // Item to be evaluated for eligibiity "supportingInfoSequence" : ["<positiveInt>"], // Applicable exception or supporting information "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "modifier" : [{ CodeableConcept }], // Product or service billing modifiers "provider" : { Reference(Practitioner|PractitionerRole) }, // Perfoming practitioner "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "facility" : { Reference(Location|Organization) }, // Servicing facility "diagnosis" : [{ // Applicable diagnosis // diagnosis[x]: Nature of illness or problem. One of these 2: "diagnosisCodeableConcept" : { CodeableConcept } "diagnosisReference" : { Reference(Condition) } }], "detail" : [{ Reference(Any) }] // Product or service details }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ 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 for coverage eligiblity request fhir:CoverageEligibilityRequest.status [ code ]; # 1..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) ]; # 1..1 Intended recipient of 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 ]; # 1..1 Creation date fhir:CoverageEligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author fhir:CoverageEligibilityRequest.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the request fhir:CoverageEligibilityRequest.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer fhir:CoverageEligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing facility fhir:CoverageEligibilityRequest.supportingInfo [ # 0..* Supporting information fhir:CoverageEligibilityRequest.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier fhir:CoverageEligibilityRequest.supportingInfo.information [ Reference(Any) ]; # 1..1 Data to be provided fhir:CoverageEligibilityRequest.supportingInfo.appliesToAll [ boolean ]; # 0..1 Applies to all items ], ...; fhir:CoverageEligibilityRequest.insurance [ # 0..* Patient insurance information fhir:CoverageEligibilityRequest.insurance.focal [ boolean ]; # 0..1 Applicable coverage fhir:CoverageEligibilityRequest.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information fhir:CoverageEligibilityRequest.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number ], ...; fhir:CoverageEligibilityRequest.item [ # 0..* Item to be evaluated for eligibiity fhir:CoverageEligibilityRequest.item.supportingInfoSequence [ positiveInt ], ... ; # 0..* Applicable exception or supporting information fhir:CoverageEligibilityRequest.item.category [ CodeableConcept ]; # 0..1 Benefit classification fhir:CoverageEligibilityRequest.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code fhir:CoverageEligibilityRequest.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service 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 item fhir:CoverageEligibilityRequest.item.facility [ Reference(Location|Organization) ]; # 0..1 Servicing facility fhir:CoverageEligibilityRequest.item.diagnosis [ # 0..* Applicable diagnosis # CoverageEligibilityRequest.item.diagnosis.diagnosis[x] : 0..1 Nature of illness or problem. 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
CoverageEligibilityRequest | |
CoverageEligibilityRequest.status |
|
CoverageEligibilityRequest.purpose |
|
See the Full Difference for further information
See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis a
Path | Definition | Type | Reference |
---|---|---|---|
CoverageEligibilityRequest.status | A code specifying the state of the resource instance. | Required | FinancialResourceStatusCodes |
CoverageEligibilityRequest.priority | The timeliness with which processing is required: STAT, normal, Deferred. | Example | ProcessPriorityCodes |
CoverageEligibilityRequest.purpose | A code specifying the types of information being requested. | Required | EligibilityRequestPurpose |
CoverageEligibilityRequest.item.category | Benefit categories such as: oral, medical, vision etc. | Example | BenefitCategoryCodes |
CoverageEligibilityRequest.item.productOrService | Allowable service and product codes. | Example | USCLSCodes |
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. | Example | ModifierTypeCodes |
CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | ICD10 Diagnostic codes. | Example | ICD-10Codes |
Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Expression | In Common |
created N | date | The creation date for the EOB | CoverageEligibilityRequest.created | |
enterer | reference | The party who is responsible for the request | CoverageEligibilityRequest.enterer (Practitioner, PractitionerRole) | |
facility | reference | Facility responsible for the goods and services | CoverageEligibilityRequest.facility (Location) | |
identifier | token | The business identifier of the Eligibility | CoverageEligibilityRequest.identifier | |
patient | reference | The reference to the patient | CoverageEligibilityRequest.patient (Patient) | |
provider | reference | The reference to the provider | CoverageEligibilityRequest.provider (Practitioner, Organization, PractitionerRole) | |
status N | token | The status of the EligibilityRequest | CoverageEligibilityRequest.status |