Release 5 Preview #2
FinancialThis 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: N/A | Standards Status: Informative | Compartments: Patient, Practitioner |
Raw JSON (canonical form + also see JSON Format Specification)
StructureDefinition for coverageeligibilityrequest
{
"resourceType" : "StructureDefinition",
"id" : "CoverageEligibilityRequest",
"meta" : {
"lastUpdated" : "2020-05-03T08:43:35.811+10:00"
},
"text" : {
"status" : "generated",
"div" : "<div>!-- Snipped for Brevity --></div>"
},
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString" : "Financial.Support"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode" : "trial-use"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger" : 2
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
"valueCode" : "patient"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode" : "fm"
}],
"url" : "http://hl7.org/fhir/StructureDefinition/CoverageEligibilityRequest",
"version" : "4.4.0",
"name" : "CoverageEligibilityRequest",
"status" : "draft",
"date" : "2020-05-03T08:43:35+10:00",
"publisher" : "Health Level Seven International (Financial Management)",
"contact" : [{
"telecom" : [{
"system" : "url",
"value" : "http://hl7.org/fhir"
}]
},
{
"telecom" : [{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/fm/index.cfm"
}]
}],
"description" : "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.",
"fhirVersion" : "4.4.0",
"mapping" : [{
"identity" : "workflow",
"uri" : "http://hl7.org/fhir/workflow",
"name" : "Workflow Pattern"
},
{
"identity" : "w5",
"uri" : "http://hl7.org/fhir/fivews",
"name" : "FiveWs Pattern Mapping"
},
{
"identity" : "v2",
"uri" : "http://hl7.org/v2",
"name" : "HL7 v2 Mapping"
},
{
"identity" : "rim",
"uri" : "http://hl7.org/v3",
"name" : "RIM Mapping"
}],
"kind" : "resource",
"abstract" : false,
"type" : "CoverageEligibilityRequest",
"baseDefinition" : "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation" : "specialization",
"snapshot" : {
"element" : [{
"id" : "CoverageEligibilityRequest",
"path" : "CoverageEligibilityRequest",
"short" : "CoverageEligibilityRequest resource",
"definition" : "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.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest",
"min" : 0,
"max" : "*"
},
"constraint" : [{
"key" : "dom-2",
"severity" : "error",
"human" : "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression" : "contained.contained.empty()",
"xpath" : "not(parent::f:contained and f:contained)",
"source" : "http://hl7.org/fhir/StructureDefinition/DomainResource"
},
{
"key" : "dom-3",
"severity" : "error",
"human" : "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource",
"expression" : "contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()",
"xpath" : "not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
"source" : "http://hl7.org/fhir/StructureDefinition/DomainResource"
},
{
"key" : "dom-4",
"severity" : "error",
"human" : "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression" : "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath" : "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source" : "http://hl7.org/fhir/StructureDefinition/DomainResource"
},
{
"key" : "dom-5",
"severity" : "error",
"human" : "If a resource is contained in another resource, it SHALL NOT have a security label",
"expression" : "contained.meta.security.empty()",
"xpath" : "not(exists(f:contained/*/f:meta/f:security))",
"source" : "http://hl7.org/fhir/StructureDefinition/DomainResource"
},
{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation",
"valueMarkdown" : "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time."
}],
"key" : "dom-6",
"severity" : "warning",
"human" : "A resource should have narrative for robust management",
"expression" : "text.`div`.exists()",
"xpath" : "exists(f:text/h:div)",
"source" : "http://hl7.org/fhir/StructureDefinition/DomainResource"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "Entity. Role, or Act"
},
{
"identity" : "workflow",
"map" : "Request"
}]
},
{
"id" : "CoverageEligibilityRequest.id",
"path" : "CoverageEligibilityRequest.id",
"short" : "Logical id of this artifact",
"definition" : "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment" : "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Resource.id",
"min" : 0,
"max" : "1"
},
"type" : [{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUri" : "id"
}],
"code" : "http://hl7.org/fhirpath/System.String"
}],
"isModifier" : false,
"isSummary" : true
},
{
"id" : "CoverageEligibilityRequest.meta",
"path" : "CoverageEligibilityRequest.meta",
"short" : "Metadata about the resource",
"definition" : "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Resource.meta",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Meta"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : true
},
{
"id" : "CoverageEligibilityRequest.implicitRules",
"path" : "CoverageEligibilityRequest.implicitRules",
"short" : "A set of rules under which this content was created",
"definition" : "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.",
"comment" : "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Resource.implicitRules",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "uri"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : true,
"isModifierReason" : "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary" : true
},
{
"id" : "CoverageEligibilityRequest.language",
"path" : "CoverageEligibilityRequest.language",
"short" : "Language of the resource content",
"definition" : "The base language in which the resource is written.",
"comment" : "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Resource.language",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "code"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical" : "http://hl7.org/fhir/ValueSet/all-languages"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "Language"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean" : true
}],
"strength" : "preferred",
"description" : "A human language.",
"valueSet" : "http://hl7.org/fhir/ValueSet/languages"
}
},
{
"id" : "CoverageEligibilityRequest.text",
"path" : "CoverageEligibilityRequest.text",
"short" : "Text summary of the resource, for human interpretation",
"definition" : "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comment" : "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.",
"alias" : ["narrative",
"html",
"xhtml",
"display"],
"min" : 0,
"max" : "1",
"base" : {
"path" : "DomainResource.text",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Narrative"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "Act.text?"
}]
},
{
"id" : "CoverageEligibilityRequest.contained",
"path" : "CoverageEligibilityRequest.contained",
"short" : "Contained, inline Resources",
"definition" : "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comment" : "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.",
"alias" : ["inline resources",
"anonymous resources",
"contained resources"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.contained",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Resource"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "N/A"
}]
},
{
"id" : "CoverageEligibilityRequest.extension",
"path" : "CoverageEligibilityRequest.extension",
"short" : "Additional content defined by implementations",
"definition" : "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias" : ["extensions",
"user content"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "N/A"
}]
},
{
"id" : "CoverageEligibilityRequest.modifierExtension",
"path" : "CoverageEligibilityRequest.modifierExtension",
"short" : "Extensions that cannot be ignored",
"definition" : "May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"requirements" : "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).",
"alias" : ["extensions",
"user content"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.modifierExtension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : true,
"isModifierReason" : "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them",
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "N/A"
}]
},
{
"id" : "CoverageEligibilityRequest.identifier",
"path" : "CoverageEligibilityRequest.identifier",
"short" : "Business Identifier for coverage eligiblity request",
"definition" : "A unique identifier assigned to this coverage eligiblity request.",
"requirements" : "Allows coverage eligibility requests to be distinguished and referenced.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.identifier",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Identifier"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.identifier"
},
{
"identity" : "w5",
"map" : "FiveWs.identifier"
}]
},
{
"id" : "CoverageEligibilityRequest.status",
"path" : "CoverageEligibilityRequest.status",
"short" : "active | cancelled | draft | entered-in-error",
"definition" : "The status of the resource instance.",
"comment" : "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"requirements" : "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.status",
"min" : 1,
"max" : "1"
},
"type" : [{
"code" : "code"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : true,
"isModifierReason" : "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary" : true,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "EligibilityRequestStatus"
}],
"strength" : "required",
"description" : "A code specifying the state of the resource instance.",
"valueSet" : "http://hl7.org/fhir/ValueSet/fm-status|4.4.0"
},
"mapping" : [{
"identity" : "workflow",
"map" : "Request.status"
},
{
"identity" : "w5",
"map" : "FiveWs.status"
}]
},
{
"id" : "CoverageEligibilityRequest.priority",
"path" : "CoverageEligibilityRequest.priority",
"short" : "Desired processing priority",
"definition" : "When the requestor expects the processor to complete processing.",
"requirements" : "Needed to advise the prossesor on the urgency of the request.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.priority",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "CodeableConcept"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "ProcessPriority"
}],
"strength" : "example",
"description" : "The timeliness with which processing is required: STAT, normal, Deferred.",
"valueSet" : "http://hl7.org/fhir/ValueSet/process-priority"
},
"mapping" : [{
"identity" : "workflow",
"map" : "Request.priority"
},
{
"identity" : "w5",
"map" : "FiveWs.class"
}]
},
{
"id" : "CoverageEligibilityRequest.purpose",
"path" : "CoverageEligibilityRequest.purpose",
"short" : "auth-requirements | benefits | discovery | validation",
"definition" : "Code to 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 the patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.",
"requirements" : "To indicate the processing actions requested.",
"min" : 1,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.purpose",
"min" : 1,
"max" : "*"
},
"type" : [{
"code" : "code"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : true,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "EligibilityRequestPurpose"
}],
"strength" : "required",
"description" : "A code specifying the types of information being requested.",
"valueSet" : "http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.4.0"
},
"mapping" : [{
"identity" : "w5",
"map" : "FiveWs.class"
}]
},
{
"id" : "CoverageEligibilityRequest.patient",
"path" : "CoverageEligibilityRequest.patient",
"short" : "Intended recipient of products and services",
"definition" : "The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.",
"comment" : "1..1.",
"requirements" : "Required to provide context and coverage validation.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.patient",
"min" : 1,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Patient"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : true,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.subject"
},
{
"identity" : "w5",
"map" : "FiveWs.subject[x]"
},
{
"identity" : "w5",
"map" : "FiveWs.subject"
}]
},
{
"id" : "CoverageEligibilityRequest.serviced[x]",
"path" : "CoverageEligibilityRequest.serviced[x]",
"short" : "Estimated date or dates of service",
"definition" : "The date or dates when the enclosed suite of services were performed or completed.",
"requirements" : "Required to provide time context for the request.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.serviced[x]",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "date"
},
{
"code" : "Period"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "w5",
"map" : "FiveWs.done[x]"
}]
},
{
"id" : "CoverageEligibilityRequest.created",
"path" : "CoverageEligibilityRequest.created",
"short" : "Creation date",
"definition" : "The date when this resource was created.",
"requirements" : "Need to record a timestamp for use by both the recipient and the issuer.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.created",
"min" : 1,
"max" : "1"
},
"type" : [{
"code" : "dateTime"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : true,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.authoredOn"
},
{
"identity" : "w5",
"map" : "FiveWs.recorded"
}]
},
{
"id" : "CoverageEligibilityRequest.enterer",
"path" : "CoverageEligibilityRequest.enterer",
"short" : "Author",
"definition" : "Person who created the request.",
"requirements" : "Some jurisdictions require the contact information for personnel completing eligibility requests.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.enterer",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "w5",
"map" : "FiveWs.author"
}]
},
{
"id" : "CoverageEligibilityRequest.provider",
"path" : "CoverageEligibilityRequest.provider",
"short" : "Party responsible for the request",
"definition" : "The provider which is responsible for the request.",
"comment" : "Typically this field would be 1..1 where this party is responsible for the eligibility request but not necessarily professionally responsible for the provision of the individual products and services listed below.",
"requirements" : "Needed to identify the requestor.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.provider",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.requester"
},
{
"identity" : "w5",
"map" : "FiveWs.source"
}]
},
{
"id" : "CoverageEligibilityRequest.insurer",
"path" : "CoverageEligibilityRequest.insurer",
"short" : "Coverage issuer",
"definition" : "The Insurer who issued the coverage in question and is the recipient of the request.",
"requirements" : "Need to identify the recipient.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.insurer",
"min" : 1,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Organization"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : true,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.performer"
},
{
"identity" : "w5",
"map" : "FiveWs.who"
}]
},
{
"id" : "CoverageEligibilityRequest.facility",
"path" : "CoverageEligibilityRequest.facility",
"short" : "Servicing facility",
"definition" : "Facility where the services are intended to be provided.",
"requirements" : "Insurance adjudication can be dependant on where services were delivered.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.facility",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Location"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "w5",
"map" : "FiveWs.where[x]"
}]
},
{
"id" : "CoverageEligibilityRequest.supportingInfo",
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "SupportingInformation"
}],
"path" : "CoverageEligibilityRequest.supportingInfo",
"short" : "Supporting information",
"definition" : "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.",
"comment" : "Often there are multiple jurisdiction specific valuesets which are required.",
"requirements" : "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.supportingInfo",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "BackboneElement"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.id",
"path" : "CoverageEligibilityRequest.supportingInfo.id",
"representation" : ["xmlAttr"],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUri" : "id"
}],
"code" : "http://hl7.org/fhirpath/System.String"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "n/a"
}]
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.extension",
"path" : "CoverageEligibilityRequest.supportingInfo.extension",
"short" : "Additional content defined by implementations",
"definition" : "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias" : ["extensions",
"user content"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "Element.extension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "n/a"
}]
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.modifierExtension",
"path" : "CoverageEligibilityRequest.supportingInfo.modifierExtension",
"short" : "Extensions that cannot be ignored even if unrecognized",
"definition" : "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"requirements" : "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).",
"alias" : ["extensions",
"user content",
"modifiers"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "BackboneElement.modifierExtension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : true,
"isModifierReason" : "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary" : true,
"mapping" : [{
"identity" : "rim",
"map" : "N/A"
}]
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.sequence",
"path" : "CoverageEligibilityRequest.supportingInfo.sequence",
"short" : "Information instance identifier",
"definition" : "A number to uniquely identify supporting information entries.",
"requirements" : "Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.supportingInfo.sequence",
"min" : 1,
"max" : "1"
},
"type" : [{
"code" : "positiveInt"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.information",
"path" : "CoverageEligibilityRequest.supportingInfo.information",
"short" : "Data to be provided",
"definition" : "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"comment" : "Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.",
"requirements" : "To convey the data content to be provided when the information is more than a simple code or period.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.supportingInfo.information",
"min" : 1,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Resource"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"path" : "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"short" : "Applies to all items",
"definition" : "The supporting materials are applicable for all detail items, product/servce categories and specific billing codes.",
"requirements" : "Needed to convey that the information is universal to the request.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "boolean"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.insurance",
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Insurance"
}],
"path" : "CoverageEligibilityRequest.insurance",
"short" : "Patient insurance information",
"definition" : "Financial instruments for reimbursement for the health care products and services.",
"comment" : "All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.",
"requirements" : "There must be at least one coverage for which eligibility is requested.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.insurance",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "BackboneElement"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.insurance.id",
"path" : "CoverageEligibilityRequest.insurance.id",
"representation" : ["xmlAttr"],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUri" : "id"
}],
"code" : "http://hl7.org/fhirpath/System.String"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "n/a"
}]
},
{
"id" : "CoverageEligibilityRequest.insurance.extension",
"path" : "CoverageEligibilityRequest.insurance.extension",
"short" : "Additional content defined by implementations",
"definition" : "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias" : ["extensions",
"user content"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "Element.extension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "n/a"
}]
},
{
"id" : "CoverageEligibilityRequest.insurance.modifierExtension",
"path" : "CoverageEligibilityRequest.insurance.modifierExtension",
"short" : "Extensions that cannot be ignored even if unrecognized",
"definition" : "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"requirements" : "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).",
"alias" : ["extensions",
"user content",
"modifiers"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "BackboneElement.modifierExtension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : true,
"isModifierReason" : "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary" : true,
"mapping" : [{
"identity" : "rim",
"map" : "N/A"
}]
},
{
"id" : "CoverageEligibilityRequest.insurance.focal",
"path" : "CoverageEligibilityRequest.insurance.focal",
"short" : "Applicable coverage",
"definition" : "A flag to indicate that this Coverage is to be used for evaluation of this request when set to true.",
"comment" : "A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for evaluating this request. Other requests would be created to request evaluation against the other listed policies.",
"requirements" : "To identify which coverage in the list is being used to evaluate this request.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.insurance.focal",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "boolean"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.insurance.coverage",
"path" : "CoverageEligibilityRequest.insurance.coverage",
"short" : "Insurance information",
"definition" : "Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.",
"requirements" : "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.insurance.coverage",
"min" : 1,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Coverage"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.insurance.businessArrangement",
"path" : "CoverageEligibilityRequest.insurance.businessArrangement",
"short" : "Additional provider contract number",
"definition" : "A business agreement number established between the provider and the insurer for special business processing purposes.",
"requirements" : "Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.insurance.businessArrangement",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "string"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.item",
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Details"
}],
"path" : "CoverageEligibilityRequest.item",
"short" : "Item to be evaluated for eligibiity",
"definition" : "Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor.",
"requirements" : "The items to be processed for the request.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.item",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "BackboneElement"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.item.id",
"path" : "CoverageEligibilityRequest.item.id",
"representation" : ["xmlAttr"],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUri" : "id"
}],
"code" : "http://hl7.org/fhirpath/System.String"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "n/a"
}]
},
{
"id" : "CoverageEligibilityRequest.item.extension",
"path" : "CoverageEligibilityRequest.item.extension",
"short" : "Additional content defined by implementations",
"definition" : "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias" : ["extensions",
"user content"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "Element.extension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "n/a"
}]
},
{
"id" : "CoverageEligibilityRequest.item.modifierExtension",
"path" : "CoverageEligibilityRequest.item.modifierExtension",
"short" : "Extensions that cannot be ignored even if unrecognized",
"definition" : "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"requirements" : "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).",
"alias" : ["extensions",
"user content",
"modifiers"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "BackboneElement.modifierExtension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : true,
"isModifierReason" : "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary" : true,
"mapping" : [{
"identity" : "rim",
"map" : "N/A"
}]
},
{
"id" : "CoverageEligibilityRequest.item.supportingInfoSequence",
"path" : "CoverageEligibilityRequest.item.supportingInfoSequence",
"short" : "Applicable exception or supporting information",
"definition" : "Exceptions, special conditions and supporting information applicable for this service or product line.",
"requirements" : "Needed to support or inform the consideration for eligibility.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.item.supportingInfoSequence",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "positiveInt"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.item.category",
"path" : "CoverageEligibilityRequest.item.category",
"short" : "Benefit classification",
"definition" : "Code to identify the general type of benefits under which products and services are provided.",
"comment" : "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"requirements" : "Needed to convey the category of service or product for which eligibility is sought.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.item.category",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "CodeableConcept"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "BenefitCategory"
}],
"strength" : "example",
"description" : "Benefit categories such as: oral, medical, vision etc.",
"valueSet" : "http://hl7.org/fhir/ValueSet/ex-benefitcategory"
}
},
{
"id" : "CoverageEligibilityRequest.item.productOrService",
"path" : "CoverageEligibilityRequest.item.productOrService",
"short" : "Billing, service, product, or drug code",
"definition" : "This contains the product, service, drug or other billing code for the item.",
"comment" : "Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).",
"requirements" : "Needed to convey the actual service or product for which eligibility is sought.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.item.productOrService",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "CodeableConcept"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "ServiceProduct"
}],
"strength" : "example",
"description" : "Allowable service and product codes.",
"valueSet" : "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id" : "CoverageEligibilityRequest.item.modifier",
"path" : "CoverageEligibilityRequest.item.modifier",
"short" : "Product or service billing modifiers",
"definition" : "Item typification or modifiers codes to convey additional context for the product or service.",
"comment" : "For example in 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.",
"requirements" : "To support provision of the item or to charge an elevated fee.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.item.modifier",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "CodeableConcept"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "Modifiers"
}],
"strength" : "example",
"description" : "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSet" : "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id" : "CoverageEligibilityRequest.item.provider",
"path" : "CoverageEligibilityRequest.item.provider",
"short" : "Perfoming practitioner",
"definition" : "The practitioner who is responsible for the product or service to be rendered to the patient.",
"requirements" : "Needed to support the evaluation of the eligibility.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.item.provider",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.requester"
},
{
"identity" : "w5",
"map" : "FiveWs.source"
}]
},
{
"id" : "CoverageEligibilityRequest.item.quantity",
"path" : "CoverageEligibilityRequest.item.quantity",
"short" : "Count of products or services",
"definition" : "The number of repetitions of a service or product.",
"requirements" : "Required when the product or service code does not convey the quantity provided.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.item.quantity",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Quantity",
"profile" : ["http://hl7.org/fhir/StructureDefinition/SimpleQuantity"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.item.unitPrice",
"path" : "CoverageEligibilityRequest.item.unitPrice",
"short" : "Fee, charge or cost per item",
"definition" : "The amount charged to the patient by the provider for a single unit.",
"requirements" : "Needed to support the evaluation of the eligibility.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.item.unitPrice",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Money"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.item.facility",
"path" : "CoverageEligibilityRequest.item.facility",
"short" : "Servicing facility",
"definition" : "Facility where the services will be provided.",
"requirements" : "Needed to support the evaluation of the eligibility.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.item.facility",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Location",
"http://hl7.org/fhir/StructureDefinition/Organization"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "CoverageEligibilityRequest.item.diagnosis",
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Diagnosis"
}],
"path" : "CoverageEligibilityRequest.item.diagnosis",
"short" : "Applicable diagnosis",
"definition" : "Patient diagnosis for which care is sought.",
"requirements" : "Needed to support the evaluation of the eligibility.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.item.diagnosis",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "BackboneElement"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "v2",
"map" : "Request.reasonReference"
}]
},
{
"id" : "CoverageEligibilityRequest.item.diagnosis.id",
"path" : "CoverageEligibilityRequest.item.diagnosis.id",
"representation" : ["xmlAttr"],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUri" : "id"
}],
"code" : "http://hl7.org/fhirpath/System.String"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "n/a"
}]
},
{
"id" : "CoverageEligibilityRequest.item.diagnosis.extension",
"path" : "CoverageEligibilityRequest.item.diagnosis.extension",
"short" : "Additional content defined by implementations",
"definition" : "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias" : ["extensions",
"user content"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "Element.extension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : false,
"isSummary" : false,
"mapping" : [{
"identity" : "rim",
"map" : "n/a"
}]
},
{
"id" : "CoverageEligibilityRequest.item.diagnosis.modifierExtension",
"path" : "CoverageEligibilityRequest.item.diagnosis.modifierExtension",
"short" : "Extensions that cannot be ignored even if unrecognized",
"definition" : "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"requirements" : "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).",
"alias" : ["extensions",
"user content",
"modifiers"],
"min" : 0,
"max" : "*",
"base" : {
"path" : "BackboneElement.modifierExtension",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Extension"
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
},
{
"key" : "ext-1",
"severity" : "error",
"human" : "Must have either extensions or value[x], not both",
"expression" : "extension.exists() != value.exists()",
"xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source" : "http://hl7.org/fhir/StructureDefinition/Extension"
}],
"isModifier" : true,
"isModifierReason" : "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary" : true,
"mapping" : [{
"identity" : "rim",
"map" : "N/A"
}]
},
{
"id" : "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"path" : "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"short" : "Nature of illness or problem",
"definition" : "The nature of illness or problem in a coded form or as a reference to an external defined Condition.",
"requirements" : "Provides health context for the evaluation of the products and/or services.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"min" : 0,
"max" : "1"
},
"type" : [{
"code" : "CodeableConcept"
},
{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Condition"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "ICD10"
}],
"strength" : "example",
"description" : "ICD10 Diagnostic codes.",
"valueSet" : "http://hl7.org/fhir/ValueSet/icd-10"
}
},
{
"id" : "CoverageEligibilityRequest.item.detail",
"path" : "CoverageEligibilityRequest.item.detail",
"short" : "Product or service details",
"definition" : "The plan/proposal/order describing the proposed service in detail.",
"requirements" : "Needed to provide complex service proposal such as a Device or a plan.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "CoverageEligibilityRequest.item.detail",
"min" : 0,
"max" : "*"
},
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Resource"]
}],
"constraint" : [{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "http://hl7.org/fhir/StructureDefinition/Element"
}],
"isModifier" : false,
"isSummary" : false
}]
},
"differential" : {
"element" : [{
"id" : "CoverageEligibilityRequest",
"path" : "CoverageEligibilityRequest",
"short" : "CoverageEligibilityRequest resource",
"definition" : "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.",
"min" : 0,
"max" : "*",
"mapping" : [{
"identity" : "workflow",
"map" : "Request"
}]
},
{
"id" : "CoverageEligibilityRequest.identifier",
"path" : "CoverageEligibilityRequest.identifier",
"short" : "Business Identifier for coverage eligiblity request",
"definition" : "A unique identifier assigned to this coverage eligiblity request.",
"requirements" : "Allows coverage eligibility requests to be distinguished and referenced.",
"min" : 0,
"max" : "*",
"type" : [{
"code" : "Identifier"
}],
"mapping" : [{
"identity" : "workflow",
"map" : "Request.identifier"
},
{
"identity" : "w5",
"map" : "FiveWs.identifier"
}]
},
{
"id" : "CoverageEligibilityRequest.status",
"path" : "CoverageEligibilityRequest.status",
"short" : "active | cancelled | draft | entered-in-error",
"definition" : "The status of the resource instance.",
"comment" : "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"requirements" : "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.",
"min" : 1,
"max" : "1",
"type" : [{
"code" : "code"
}],
"isModifier" : true,
"isModifierReason" : "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary" : true,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "EligibilityRequestStatus"
}],
"strength" : "required",
"description" : "A code specifying the state of the resource instance.",
"valueSet" : "http://hl7.org/fhir/ValueSet/fm-status|4.4.0"
},
"mapping" : [{
"identity" : "workflow",
"map" : "Request.status"
},
{
"identity" : "w5",
"map" : "FiveWs.status"
}]
},
{
"id" : "CoverageEligibilityRequest.priority",
"path" : "CoverageEligibilityRequest.priority",
"short" : "Desired processing priority",
"definition" : "When the requestor expects the processor to complete processing.",
"requirements" : "Needed to advise the prossesor on the urgency of the request.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "CodeableConcept"
}],
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "ProcessPriority"
}],
"strength" : "example",
"description" : "The timeliness with which processing is required: STAT, normal, Deferred.",
"valueSet" : "http://hl7.org/fhir/ValueSet/process-priority"
},
"mapping" : [{
"identity" : "workflow",
"map" : "Request.priority"
},
{
"identity" : "w5",
"map" : "FiveWs.class"
}]
},
{
"id" : "CoverageEligibilityRequest.purpose",
"path" : "CoverageEligibilityRequest.purpose",
"short" : "auth-requirements | benefits | discovery | validation",
"definition" : "Code to 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 the patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.",
"requirements" : "To indicate the processing actions requested.",
"min" : 1,
"max" : "*",
"type" : [{
"code" : "code"
}],
"isSummary" : true,
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "EligibilityRequestPurpose"
}],
"strength" : "required",
"description" : "A code specifying the types of information being requested.",
"valueSet" : "http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.4.0"
},
"mapping" : [{
"identity" : "w5",
"map" : "FiveWs.class"
}]
},
{
"id" : "CoverageEligibilityRequest.patient",
"path" : "CoverageEligibilityRequest.patient",
"short" : "Intended recipient of products and services",
"definition" : "The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.",
"comment" : "1..1.",
"requirements" : "Required to provide context and coverage validation.",
"min" : 1,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Patient"]
}],
"isSummary" : true,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.subject"
},
{
"identity" : "w5",
"map" : "FiveWs.subject[x]"
},
{
"identity" : "w5",
"map" : "FiveWs.subject"
}]
},
{
"id" : "CoverageEligibilityRequest.serviced[x]",
"path" : "CoverageEligibilityRequest.serviced[x]",
"short" : "Estimated date or dates of service",
"definition" : "The date or dates when the enclosed suite of services were performed or completed.",
"requirements" : "Required to provide time context for the request.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "date"
},
{
"code" : "Period"
}],
"mapping" : [{
"identity" : "w5",
"map" : "FiveWs.done[x]"
}]
},
{
"id" : "CoverageEligibilityRequest.created",
"path" : "CoverageEligibilityRequest.created",
"short" : "Creation date",
"definition" : "The date when this resource was created.",
"requirements" : "Need to record a timestamp for use by both the recipient and the issuer.",
"min" : 1,
"max" : "1",
"type" : [{
"code" : "dateTime"
}],
"isSummary" : true,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.authoredOn"
},
{
"identity" : "w5",
"map" : "FiveWs.recorded"
}]
},
{
"id" : "CoverageEligibilityRequest.enterer",
"path" : "CoverageEligibilityRequest.enterer",
"short" : "Author",
"definition" : "Person who created the request.",
"requirements" : "Some jurisdictions require the contact information for personnel completing eligibility requests.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole"]
}],
"mapping" : [{
"identity" : "w5",
"map" : "FiveWs.author"
}]
},
{
"id" : "CoverageEligibilityRequest.provider",
"path" : "CoverageEligibilityRequest.provider",
"short" : "Party responsible for the request",
"definition" : "The provider which is responsible for the request.",
"comment" : "Typically this field would be 1..1 where this party is responsible for the eligibility request but not necessarily professionally responsible for the provision of the individual products and services listed below.",
"requirements" : "Needed to identify the requestor.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization"]
}],
"mapping" : [{
"identity" : "workflow",
"map" : "Request.requester"
},
{
"identity" : "w5",
"map" : "FiveWs.source"
}]
},
{
"id" : "CoverageEligibilityRequest.insurer",
"path" : "CoverageEligibilityRequest.insurer",
"short" : "Coverage issuer",
"definition" : "The Insurer who issued the coverage in question and is the recipient of the request.",
"requirements" : "Need to identify the recipient.",
"min" : 1,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Organization"]
}],
"isSummary" : true,
"mapping" : [{
"identity" : "workflow",
"map" : "Request.performer"
},
{
"identity" : "w5",
"map" : "FiveWs.who"
}]
},
{
"id" : "CoverageEligibilityRequest.facility",
"path" : "CoverageEligibilityRequest.facility",
"short" : "Servicing facility",
"definition" : "Facility where the services are intended to be provided.",
"requirements" : "Insurance adjudication can be dependant on where services were delivered.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Location"]
}],
"mapping" : [{
"identity" : "w5",
"map" : "FiveWs.where[x]"
}]
},
{
"id" : "CoverageEligibilityRequest.supportingInfo",
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "SupportingInformation"
}],
"path" : "CoverageEligibilityRequest.supportingInfo",
"short" : "Supporting information",
"definition" : "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.",
"comment" : "Often there are multiple jurisdiction specific valuesets which are required.",
"requirements" : "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min" : 0,
"max" : "*",
"type" : [{
"code" : "BackboneElement"
}]
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.sequence",
"path" : "CoverageEligibilityRequest.supportingInfo.sequence",
"short" : "Information instance identifier",
"definition" : "A number to uniquely identify supporting information entries.",
"requirements" : "Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.",
"min" : 1,
"max" : "1",
"type" : [{
"code" : "positiveInt"
}]
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.information",
"path" : "CoverageEligibilityRequest.supportingInfo.information",
"short" : "Data to be provided",
"definition" : "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"comment" : "Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.",
"requirements" : "To convey the data content to be provided when the information is more than a simple code or period.",
"min" : 1,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Resource"]
}]
},
{
"id" : "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"path" : "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"short" : "Applies to all items",
"definition" : "The supporting materials are applicable for all detail items, product/servce categories and specific billing codes.",
"requirements" : "Needed to convey that the information is universal to the request.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "boolean"
}]
},
{
"id" : "CoverageEligibilityRequest.insurance",
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Insurance"
}],
"path" : "CoverageEligibilityRequest.insurance",
"short" : "Patient insurance information",
"definition" : "Financial instruments for reimbursement for the health care products and services.",
"comment" : "All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.",
"requirements" : "There must be at least one coverage for which eligibility is requested.",
"min" : 0,
"max" : "*",
"type" : [{
"code" : "BackboneElement"
}]
},
{
"id" : "CoverageEligibilityRequest.insurance.focal",
"path" : "CoverageEligibilityRequest.insurance.focal",
"short" : "Applicable coverage",
"definition" : "A flag to indicate that this Coverage is to be used for evaluation of this request when set to true.",
"comment" : "A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for evaluating this request. Other requests would be created to request evaluation against the other listed policies.",
"requirements" : "To identify which coverage in the list is being used to evaluate this request.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "boolean"
}]
},
{
"id" : "CoverageEligibilityRequest.insurance.coverage",
"path" : "CoverageEligibilityRequest.insurance.coverage",
"short" : "Insurance information",
"definition" : "Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.",
"requirements" : "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min" : 1,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Coverage"]
}]
},
{
"id" : "CoverageEligibilityRequest.insurance.businessArrangement",
"path" : "CoverageEligibilityRequest.insurance.businessArrangement",
"short" : "Additional provider contract number",
"definition" : "A business agreement number established between the provider and the insurer for special business processing purposes.",
"requirements" : "Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "string"
}]
},
{
"id" : "CoverageEligibilityRequest.item",
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Details"
}],
"path" : "CoverageEligibilityRequest.item",
"short" : "Item to be evaluated for eligibiity",
"definition" : "Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor.",
"requirements" : "The items to be processed for the request.",
"min" : 0,
"max" : "*",
"type" : [{
"code" : "BackboneElement"
}]
},
{
"id" : "CoverageEligibilityRequest.item.supportingInfoSequence",
"path" : "CoverageEligibilityRequest.item.supportingInfoSequence",
"short" : "Applicable exception or supporting information",
"definition" : "Exceptions, special conditions and supporting information applicable for this service or product line.",
"requirements" : "Needed to support or inform the consideration for eligibility.",
"min" : 0,
"max" : "*",
"type" : [{
"code" : "positiveInt"
}]
},
{
"id" : "CoverageEligibilityRequest.item.category",
"path" : "CoverageEligibilityRequest.item.category",
"short" : "Benefit classification",
"definition" : "Code to identify the general type of benefits under which products and services are provided.",
"comment" : "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"requirements" : "Needed to convey the category of service or product for which eligibility is sought.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "CodeableConcept"
}],
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "BenefitCategory"
}],
"strength" : "example",
"description" : "Benefit categories such as: oral, medical, vision etc.",
"valueSet" : "http://hl7.org/fhir/ValueSet/ex-benefitcategory"
}
},
{
"id" : "CoverageEligibilityRequest.item.productOrService",
"path" : "CoverageEligibilityRequest.item.productOrService",
"short" : "Billing, service, product, or drug code",
"definition" : "This contains the product, service, drug or other billing code for the item.",
"comment" : "Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).",
"requirements" : "Needed to convey the actual service or product for which eligibility is sought.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "CodeableConcept"
}],
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "ServiceProduct"
}],
"strength" : "example",
"description" : "Allowable service and product codes.",
"valueSet" : "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id" : "CoverageEligibilityRequest.item.modifier",
"path" : "CoverageEligibilityRequest.item.modifier",
"short" : "Product or service billing modifiers",
"definition" : "Item typification or modifiers codes to convey additional context for the product or service.",
"comment" : "For example in 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.",
"requirements" : "To support provision of the item or to charge an elevated fee.",
"min" : 0,
"max" : "*",
"type" : [{
"code" : "CodeableConcept"
}],
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "Modifiers"
}],
"strength" : "example",
"description" : "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSet" : "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id" : "CoverageEligibilityRequest.item.provider",
"path" : "CoverageEligibilityRequest.item.provider",
"short" : "Perfoming practitioner",
"definition" : "The practitioner who is responsible for the product or service to be rendered to the patient.",
"requirements" : "Needed to support the evaluation of the eligibility.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole"]
}],
"mapping" : [{
"identity" : "workflow",
"map" : "Request.requester"
},
{
"identity" : "w5",
"map" : "FiveWs.source"
}]
},
{
"id" : "CoverageEligibilityRequest.item.quantity",
"path" : "CoverageEligibilityRequest.item.quantity",
"short" : "Count of products or services",
"definition" : "The number of repetitions of a service or product.",
"requirements" : "Required when the product or service code does not convey the quantity provided.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "Quantity",
"profile" : ["http://hl7.org/fhir/StructureDefinition/SimpleQuantity"]
}]
},
{
"id" : "CoverageEligibilityRequest.item.unitPrice",
"path" : "CoverageEligibilityRequest.item.unitPrice",
"short" : "Fee, charge or cost per item",
"definition" : "The amount charged to the patient by the provider for a single unit.",
"requirements" : "Needed to support the evaluation of the eligibility.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "Money"
}]
},
{
"id" : "CoverageEligibilityRequest.item.facility",
"path" : "CoverageEligibilityRequest.item.facility",
"short" : "Servicing facility",
"definition" : "Facility where the services will be provided.",
"requirements" : "Needed to support the evaluation of the eligibility.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Location",
"http://hl7.org/fhir/StructureDefinition/Organization"]
}]
},
{
"id" : "CoverageEligibilityRequest.item.diagnosis",
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Diagnosis"
}],
"path" : "CoverageEligibilityRequest.item.diagnosis",
"short" : "Applicable diagnosis",
"definition" : "Patient diagnosis for which care is sought.",
"requirements" : "Needed to support the evaluation of the eligibility.",
"min" : 0,
"max" : "*",
"type" : [{
"code" : "BackboneElement"
}],
"mapping" : [{
"identity" : "v2",
"map" : "Request.reasonReference"
}]
},
{
"id" : "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"path" : "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"short" : "Nature of illness or problem",
"definition" : "The nature of illness or problem in a coded form or as a reference to an external defined Condition.",
"requirements" : "Provides health context for the evaluation of the products and/or services.",
"min" : 0,
"max" : "1",
"type" : [{
"code" : "CodeableConcept"
},
{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Condition"]
}],
"binding" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "ICD10"
}],
"strength" : "example",
"description" : "ICD10 Diagnostic codes.",
"valueSet" : "http://hl7.org/fhir/ValueSet/icd-10"
}
},
{
"id" : "CoverageEligibilityRequest.item.detail",
"path" : "CoverageEligibilityRequest.item.detail",
"short" : "Product or service details",
"definition" : "The plan/proposal/order describing the proposed service in detail.",
"requirements" : "Needed to provide complex service proposal such as a Device or a plan.",
"min" : 0,
"max" : "*",
"type" : [{
"code" : "Reference",
"targetProfile" : ["http://hl7.org/fhir/StructureDefinition/Resource"]
}]
}]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
FHIR ®© HL7.org 2011+. FHIR CI Build hl7.fhir.core#4.4.0 generated on Sun, May 3, 2020 08:46+1000.
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