Release 5 Preview #3

This page is part of the FHIR Specification (v4.5.0: R5 Preview #3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

13.2 Resource CoverageEligibilityRequest - Content

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

The CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.

13.2.1 Scope and Usage

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

The CoverageEligibilityRequest resource is a "event" resource from a FHIR workflow perspective - see Workflow Event.

13.2.1.1 Additional Information

Additional information regarding electronic coverage eligibility content and usage may be found at:

  • Financial Resource Status Lifecycle: how .status is used in the financial resources.
  • Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
  • Batches: how eClaims may handle batches of eligibility, claims and responses.
  • Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This includes how payors how request additional supporting information from providers.

13.2.2 Boundaries and Relationships

CoverageEligibilityRequest should be used when requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage.

The Claim resource should be used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

The Coverage resource contains the information typically found on the health insurance card for an individual used to identify the covered individual to the insurer and is referred to by the CoverageEligibilityRequest.

The eClaim domain includes a number of related resources

CoverageEligibilityRequest Patient and insurance coverage information provided to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
Coverage Provides the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services.

13.2.3 References

This resource is referenced by CoverageEligibilityResponse.

This resource implements the Request pattern.

13.2.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityRequest TUDomainResourceCoverageEligibilityRequest resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for coverage eligiblity request
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... patient Σ1..1Reference(Patient)Intended recipient of products and services
... serviced[x] 0..1Estimated date or dates of service
.... servicedDatedate
.... servicedPeriodPeriod
... created Σ1..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the request
... insurer Σ1..1Reference(Organization)Coverage issuer
... facility 0..1Reference(Location)Servicing facility
... supportingInfo 0..*BackboneElementSupporting information
.... sequence 1..1positiveIntInformation instance identifier
.... information 1..1Reference(Any)Data to be provided
.... appliesToAll 0..1booleanApplies to all items
... insurance 0..*BackboneElementPatient insurance information
.... focal 0..1booleanApplicable coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
... item 0..*BackboneElementItem to be evaluated for eligibiity
.... supportingInfoSequence 0..*positiveIntApplicable exception or supporting information
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
.... provider 0..1Reference(Practitioner | PractitionerRole)Perfoming practitioner
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... facility 0..1Reference(Location | Organization)Servicing facility
.... diagnosis 0..*BackboneElementApplicable diagnosis
..... diagnosis[x] 0..1Nature of illness or problem
ICD-10 Codes (Example)
...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)
.... detail 0..*Reference(Any)Product or service details

doco Documentation for this format

UML Diagram (Legend)

CoverageEligibilityRequest (DomainResource)A unique identifier assigned to this coverage eligiblity requestidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »When the requestor expects the processor to complete processingpriority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example)ProcessPriorityCodes?? »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 specifiedpurpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required)EligibilityRequestPurpose! »The party who is the beneficiary of the supplied coverage and for whom eligibility is soughtpatient : Reference [1..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : DataType [0..1] « date|Period »The date when this resource was createdcreated : dateTime [1..1]Person who created the requestenterer : Reference [0..1] « Practitioner|PractitionerRole »The provider which is responsible for the requestprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The Insurer who issued the coverage in question and is the recipient of the requestinsurer : Reference [1..1] « Organization »Facility where the services are intended to be providedfacility : Reference [0..1] « Location »SupportingInformationA number to uniquely identify supporting information entriessequence : positiveInt [1..1]Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datainformation : Reference [1..1] « Any »The supporting materials are applicable for all detail items, product/servce categories and specific billing codesappliesToAll : boolean [0..1]InsuranceA flag to indicate that this Coverage is to be used for evaluation of this request when set to truefocal : boolean [0..1]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 systemcoverage : Reference [1..1] « Coverage »A business agreement number established between the provider and the insurer for special business processing purposesbusinessArrangement : string [0..1]DetailsExceptions, special conditions and supporting information applicable for this service or product linesupportingInfoSequence : positiveInt [0..*]Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)BenefitCategoryCodes?? »This contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The practitioner who is responsible for the product or service to be rendered to the patientprovider : Reference [0..1] « Practitioner|PractitionerRole »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The amount charged to the patient by the provider for a single unitunitPrice : Money [0..1]Facility where the services will be providedfacility : Reference [0..1] « Location|Organization »The plan/proposal/order describing the proposed service in detaildetail : Reference [0..*] « Any »DiagnosisThe nature of illness or problem in a coded form or as a reference to an external defined Conditiondiagnosis[x] : DataType [0..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issuessupportingInfo[0..*]Financial instruments for reimbursement for the health care products and servicesinsurance[0..*]Patient diagnosis for which care is soughtdiagnosis[0..*]Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payoritem[0..*]

XML Template

<CoverageEligibilityRequest xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation -->
 <patient><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]>
 <created value="[dateTime]"/><!-- 1..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></provider>
 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing facility --></facility>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <information><!-- 1..1 Reference(Any) Data to be provided --></information>
  <appliesToAll value="[boolean]"/><!-- 0..1 Applies to all items -->
 </supportingInfo>
 <insurance>  <!-- 0..* Patient insurance information -->
  <focal value="[boolean]"/><!-- 0..1 Applicable coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
 </insurance>
 <item>  <!-- 0..* Item to be evaluated for eligibiity -->
  <supportingInfoSequence value="[positiveInt]"/><!-- 0..* Applicable exception or supporting information -->
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Perfoming practitioner --></provider>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility>
  <diagnosis>  <!-- 0..* Applicable diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  </diagnosis>
  <detail><!-- 0..* Reference(Any) Product or service details --></detail>
 </item>
</CoverageEligibilityRequest>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityRequest",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "priority" : { CodeableConcept }, // Desired processing priority
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "patient" : { Reference(Patient) }, // R!  Intended recipient of products and services
  // serviced[x]: Estimated date or dates of service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // R!  Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request
  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "facility" : { Reference(Location) }, // Servicing facility
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "information" : { Reference(Any) }, // R!  Data to be provided
    "appliesToAll" : <boolean> // Applies to all items
  }],
  "insurance" : [{ // Patient insurance information
    "focal" : <boolean>, // Applicable coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>" // Additional provider contract number
  }],
  "item" : [{ // Item to be evaluated for eligibiity
    "supportingInfoSequence" : ["<positiveInt>"], // Applicable exception or supporting information
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "provider" : { Reference(Practitioner|PractitionerRole) }, // Perfoming practitioner
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "facility" : { Reference(Location|Organization) }, // Servicing facility
    "diagnosis" : [{ // Applicable diagnosis
      // diagnosis[x]: Nature of illness or problem. One of these 2:
      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }],
    "detail" : [{ Reference(Any) }] // Product or service details
  }]
}

Turtle Template

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


[ a fhir:CoverageEligibilityRequest;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CoverageEligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityRequest.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:CoverageEligibilityRequest.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityRequest.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityRequest.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityRequest.servicedDate [ date ]
    fhir:CoverageEligibilityRequest.servicedPeriod [ Period ]
  fhir:CoverageEligibilityRequest.created [ dateTime ]; # 1..1 Creation date
  fhir:CoverageEligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:CoverageEligibilityRequest.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the request
  fhir:CoverageEligibilityRequest.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing facility
  fhir:CoverageEligibilityRequest.supportingInfo [ # 0..* Supporting information
    fhir:CoverageEligibilityRequest.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:CoverageEligibilityRequest.supportingInfo.information [ Reference(Any) ]; # 1..1 Data to be provided
    fhir:CoverageEligibilityRequest.supportingInfo.appliesToAll [ boolean ]; # 0..1 Applies to all items
  ], ...;
  fhir:CoverageEligibilityRequest.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityRequest.insurance.focal [ boolean ]; # 0..1 Applicable coverage
    fhir:CoverageEligibilityRequest.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityRequest.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
  ], ...;
  fhir:CoverageEligibilityRequest.item [ # 0..* Item to be evaluated for eligibiity
    fhir:CoverageEligibilityRequest.item.supportingInfoSequence [ positiveInt ], ... ; # 0..* Applicable exception or supporting information
    fhir:CoverageEligibilityRequest.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:CoverageEligibilityRequest.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
    fhir:CoverageEligibilityRequest.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:CoverageEligibilityRequest.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Perfoming practitioner
    fhir:CoverageEligibilityRequest.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:CoverageEligibilityRequest.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:CoverageEligibilityRequest.item.facility [ Reference(Location|Organization) ]; # 0..1 Servicing facility
    fhir:CoverageEligibilityRequest.item.diagnosis [ # 0..* Applicable diagnosis
      # CoverageEligibilityRequest.item.diagnosis.diagnosis[x] : 0..1 Nature of illness or problem. One of these 2
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
    fhir:CoverageEligibilityRequest.item.detail [ Reference(Any) ], ... ; # 0..* Product or service details
  ], ...;
]

Changes since R3

CoverageEligibilityRequest
CoverageEligibilityRequest.status
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.5.0
CoverageEligibilityRequest.purpose
  • Change value set from http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.0 to http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.5.0

See the Full Difference for further information

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityRequest TUDomainResourceCoverageEligibilityRequest resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for coverage eligiblity request
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... patient Σ1..1Reference(Patient)Intended recipient of products and services
... serviced[x] 0..1Estimated date or dates of service
.... servicedDatedate
.... servicedPeriodPeriod
... created Σ1..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the request
... insurer Σ1..1Reference(Organization)Coverage issuer
... facility 0..1Reference(Location)Servicing facility
... supportingInfo 0..*BackboneElementSupporting information
.... sequence 1..1positiveIntInformation instance identifier
.... information 1..1Reference(Any)Data to be provided
.... appliesToAll 0..1booleanApplies to all items
... insurance 0..*BackboneElementPatient insurance information
.... focal 0..1booleanApplicable coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
... item 0..*BackboneElementItem to be evaluated for eligibiity
.... supportingInfoSequence 0..*positiveIntApplicable exception or supporting information
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
.... provider 0..1Reference(Practitioner | PractitionerRole)Perfoming practitioner
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... facility 0..1Reference(Location | Organization)Servicing facility
.... diagnosis 0..*BackboneElementApplicable diagnosis
..... diagnosis[x] 0..1Nature of illness or problem
ICD-10 Codes (Example)
...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)
.... detail 0..*Reference(Any)Product or service details

doco Documentation for this format

UML Diagram (Legend)

CoverageEligibilityRequest (DomainResource)A unique identifier assigned to this coverage eligiblity requestidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »When the requestor expects the processor to complete processingpriority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example)ProcessPriorityCodes?? »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 specifiedpurpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required)EligibilityRequestPurpose! »The party who is the beneficiary of the supplied coverage and for whom eligibility is soughtpatient : Reference [1..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : DataType [0..1] « date|Period »The date when this resource was createdcreated : dateTime [1..1]Person who created the requestenterer : Reference [0..1] « Practitioner|PractitionerRole »The provider which is responsible for the requestprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The Insurer who issued the coverage in question and is the recipient of the requestinsurer : Reference [1..1] « Organization »Facility where the services are intended to be providedfacility : Reference [0..1] « Location »SupportingInformationA number to uniquely identify supporting information entriessequence : positiveInt [1..1]Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datainformation : Reference [1..1] « Any »The supporting materials are applicable for all detail items, product/servce categories and specific billing codesappliesToAll : boolean [0..1]InsuranceA flag to indicate that this Coverage is to be used for evaluation of this request when set to truefocal : boolean [0..1]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 systemcoverage : Reference [1..1] « Coverage »A business agreement number established between the provider and the insurer for special business processing purposesbusinessArrangement : string [0..1]DetailsExceptions, special conditions and supporting information applicable for this service or product linesupportingInfoSequence : positiveInt [0..*]Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)BenefitCategoryCodes?? »This contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The practitioner who is responsible for the product or service to be rendered to the patientprovider : Reference [0..1] « Practitioner|PractitionerRole »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The amount charged to the patient by the provider for a single unitunitPrice : Money [0..1]Facility where the services will be providedfacility : Reference [0..1] « Location|Organization »The plan/proposal/order describing the proposed service in detaildetail : Reference [0..*] « Any »DiagnosisThe nature of illness or problem in a coded form or as a reference to an external defined Conditiondiagnosis[x] : DataType [0..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issuessupportingInfo[0..*]Financial instruments for reimbursement for the health care products and servicesinsurance[0..*]Patient diagnosis for which care is soughtdiagnosis[0..*]Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payoritem[0..*]

XML Template

<CoverageEligibilityRequest xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation -->
 <patient><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]>
 <created value="[dateTime]"/><!-- 1..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></provider>
 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing facility --></facility>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <information><!-- 1..1 Reference(Any) Data to be provided --></information>
  <appliesToAll value="[boolean]"/><!-- 0..1 Applies to all items -->
 </supportingInfo>
 <insurance>  <!-- 0..* Patient insurance information -->
  <focal value="[boolean]"/><!-- 0..1 Applicable coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
 </insurance>
 <item>  <!-- 0..* Item to be evaluated for eligibiity -->
  <supportingInfoSequence value="[positiveInt]"/><!-- 0..* Applicable exception or supporting information -->
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Perfoming practitioner --></provider>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility>
  <diagnosis>  <!-- 0..* Applicable diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  </diagnosis>
  <detail><!-- 0..* Reference(Any) Product or service details --></detail>
 </item>
</CoverageEligibilityRequest>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityRequest",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "priority" : { CodeableConcept }, // Desired processing priority
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "patient" : { Reference(Patient) }, // R!  Intended recipient of products and services
  // serviced[x]: Estimated date or dates of service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // R!  Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request
  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "facility" : { Reference(Location) }, // Servicing facility
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "information" : { Reference(Any) }, // R!  Data to be provided
    "appliesToAll" : <boolean> // Applies to all items
  }],
  "insurance" : [{ // Patient insurance information
    "focal" : <boolean>, // Applicable coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>" // Additional provider contract number
  }],
  "item" : [{ // Item to be evaluated for eligibiity
    "supportingInfoSequence" : ["<positiveInt>"], // Applicable exception or supporting information
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "provider" : { Reference(Practitioner|PractitionerRole) }, // Perfoming practitioner
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "facility" : { Reference(Location|Organization) }, // Servicing facility
    "diagnosis" : [{ // Applicable diagnosis
      // diagnosis[x]: Nature of illness or problem. One of these 2:
      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }],
    "detail" : [{ Reference(Any) }] // Product or service details
  }]
}

Turtle Template

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


[ a fhir:CoverageEligibilityRequest;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CoverageEligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityRequest.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:CoverageEligibilityRequest.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityRequest.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityRequest.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityRequest.servicedDate [ date ]
    fhir:CoverageEligibilityRequest.servicedPeriod [ Period ]
  fhir:CoverageEligibilityRequest.created [ dateTime ]; # 1..1 Creation date
  fhir:CoverageEligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:CoverageEligibilityRequest.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the request
  fhir:CoverageEligibilityRequest.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing facility
  fhir:CoverageEligibilityRequest.supportingInfo [ # 0..* Supporting information
    fhir:CoverageEligibilityRequest.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:CoverageEligibilityRequest.supportingInfo.information [ Reference(Any) ]; # 1..1 Data to be provided
    fhir:CoverageEligibilityRequest.supportingInfo.appliesToAll [ boolean ]; # 0..1 Applies to all items
  ], ...;
  fhir:CoverageEligibilityRequest.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityRequest.insurance.focal [ boolean ]; # 0..1 Applicable coverage
    fhir:CoverageEligibilityRequest.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityRequest.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
  ], ...;
  fhir:CoverageEligibilityRequest.item [ # 0..* Item to be evaluated for eligibiity
    fhir:CoverageEligibilityRequest.item.supportingInfoSequence [ positiveInt ], ... ; # 0..* Applicable exception or supporting information
    fhir:CoverageEligibilityRequest.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:CoverageEligibilityRequest.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
    fhir:CoverageEligibilityRequest.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:CoverageEligibilityRequest.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Perfoming practitioner
    fhir:CoverageEligibilityRequest.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:CoverageEligibilityRequest.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:CoverageEligibilityRequest.item.facility [ Reference(Location|Organization) ]; # 0..1 Servicing facility
    fhir:CoverageEligibilityRequest.item.diagnosis [ # 0..* Applicable diagnosis
      # CoverageEligibilityRequest.item.diagnosis.diagnosis[x] : 0..1 Nature of illness or problem. One of these 2
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
    fhir:CoverageEligibilityRequest.item.detail [ Reference(Any) ], ... ; # 0..* Product or service details
  ], ...;
]

Changes since Release 3

CoverageEligibilityRequest
CoverageEligibilityRequest.status
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.5.0
CoverageEligibilityRequest.purpose
  • Change value set from http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.0 to http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.5.0

See the Full Difference for further information

This analysis is available as XML or JSON.

 

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

13.2.4.1 Terminology Bindings

PathDefinitionTypeReference
CoverageEligibilityRequest.status A code specifying the state of the resource instance.RequiredFinancialResourceStatusCodes
CoverageEligibilityRequest.priority The timeliness with which processing is required: STAT, normal, Deferred.ExampleProcessPriorityCodes
CoverageEligibilityRequest.purpose A code specifying the types of information being requested.RequiredEligibilityRequestPurpose
CoverageEligibilityRequest.item.category Benefit categories such as: oral, medical, vision etc.ExampleBenefitCategoryCodes
CoverageEligibilityRequest.item.productOrService Allowable service and product codes.ExampleUSCLSCodes
CoverageEligibilityRequest.item.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifierTypeCodes
CoverageEligibilityRequest.item.diagnosis.diagnosis[x] ICD10 Diagnostic codes.ExampleICD-10Codes

13.2.5 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

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