This page is part of the FHIR Specification (v5.0.0-ballot: R5 Ballot - see ballot notes). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4
Financial Management Work Group | Maturity Level: 2 | Trial Use | Security Category: Patient | Compartments: Patient, Practitioner |
Detailed Descriptions for the elements in the CoverageEligibilityResponse resource.
CoverageEligibilityResponse | |||||||||
Element Id | CoverageEligibilityResponse | ||||||||
Definition | This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource. | ||||||||
Short Display | CoverageEligibilityResponse resource | ||||||||
Cardinality | 0..* | ||||||||
Type | DomainResource | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.identifier | |||||||||
Element Id | CoverageEligibilityResponse.identifier | ||||||||
Definition | A unique identifier assigned to this coverage eligiblity request. | ||||||||
Short Display | Business Identifier for coverage eligiblity request | ||||||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||||||
Cardinality | 0..* | ||||||||
Type | Identifier | ||||||||
Requirements | Allows coverage eligibility requests to be distinguished and referenced. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.status | |||||||||
Element Id | CoverageEligibilityResponse.status | ||||||||
Definition | The status of the resource instance. | ||||||||
Short Display | active | cancelled | draft | entered-in-error | ||||||||
Cardinality | 1..1 | ||||||||
Terminology Binding | Financial Resource Status Codes (Required) | ||||||||
Type | code | ||||||||
Is Modifier | true (Reason: 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) | ||||||||
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'. | ||||||||
Summary | true | ||||||||
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. | ||||||||
CoverageEligibilityResponse.purpose | |||||||||
Element Id | CoverageEligibilityResponse.purpose | ||||||||
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. | ||||||||
Short Display | auth-requirements | benefits | discovery | validation | ||||||||
Cardinality | 1..* | ||||||||
Terminology Binding | EligibilityResponsePurpose (Required) | ||||||||
Type | code | ||||||||
Requirements | To indicate the processing actions requested. | ||||||||
Summary | true | ||||||||
CoverageEligibilityResponse.patient | |||||||||
Element Id | CoverageEligibilityResponse.patient | ||||||||
Definition | The party who is the beneficiary of the supplied coverage and for whom eligibility is sought. | ||||||||
Short Display | Intended recipient of products and services | ||||||||
Cardinality | 1..1 | ||||||||
Type | Reference(Patient) | ||||||||
Requirements | Required to provide context and coverage validation. | ||||||||
Summary | true | ||||||||
CoverageEligibilityResponse.serviced[x] | |||||||||
Element Id | CoverageEligibilityResponse.serviced[x] | ||||||||
Definition | The date or dates when the enclosed suite of services were performed or completed. | ||||||||
Short Display | Estimated date or dates of service | ||||||||
Cardinality | 0..1 | ||||||||
Type | date|Period | ||||||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||||||
Requirements | Required to provide time context for the request. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.created | |||||||||
Element Id | CoverageEligibilityResponse.created | ||||||||
Definition | The date this resource was created. | ||||||||
Short Display | Response creation date | ||||||||
Cardinality | 1..1 | ||||||||
Type | dateTime | ||||||||
Requirements | Need to record a timestamp for use by both the recipient and the issuer. | ||||||||
Summary | true | ||||||||
CoverageEligibilityResponse.requestor | |||||||||
Element Id | CoverageEligibilityResponse.requestor | ||||||||
Definition | The provider which is responsible for the request. | ||||||||
Short Display | Party responsible for the request | ||||||||
Cardinality | 0..1 | ||||||||
Type | Reference(Practitioner | PractitionerRole | Organization) | ||||||||
Summary | false | ||||||||
Comments | This party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner. | ||||||||
CoverageEligibilityResponse.request | |||||||||
Element Id | CoverageEligibilityResponse.request | ||||||||
Definition | Reference to the original request resource. | ||||||||
Short Display | Eligibility request reference | ||||||||
Cardinality | 1..1 | ||||||||
Type | Reference(CoverageEligibilityRequest) | ||||||||
Requirements | Needed to allow the response to be linked to the request. | ||||||||
Summary | true | ||||||||
CoverageEligibilityResponse.outcome | |||||||||
Element Id | CoverageEligibilityResponse.outcome | ||||||||
Definition | The outcome of the request processing. | ||||||||
Short Display | queued | complete | error | partial | ||||||||
Cardinality | 1..1 | ||||||||
Terminology Binding | EligibilityOutcome (Required) | ||||||||
Type | code | ||||||||
Requirements | To advise the requestor of an overall processing outcome. | ||||||||
Summary | true | ||||||||
Comments | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). | ||||||||
CoverageEligibilityResponse.disposition | |||||||||
Element Id | CoverageEligibilityResponse.disposition | ||||||||
Definition | A human readable description of the status of the adjudication. | ||||||||
Short Display | Disposition Message | ||||||||
Cardinality | 0..1 | ||||||||
Type | string | ||||||||
Requirements | Provided for user display. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurer | |||||||||
Element Id | CoverageEligibilityResponse.insurer | ||||||||
Definition | The Insurer who issued the coverage in question and is the author of the response. | ||||||||
Short Display | Coverage issuer | ||||||||
Cardinality | 1..1 | ||||||||
Type | Reference(Organization) | ||||||||
Requirements | Need to identify the author. | ||||||||
Summary | true | ||||||||
CoverageEligibilityResponse.insurance | |||||||||
Element Id | CoverageEligibilityResponse.insurance | ||||||||
Definition | Financial instruments for reimbursement for the health care products and services. | ||||||||
Short Display | Patient insurance information | ||||||||
Cardinality | 0..* | ||||||||
Requirements | There must be at least one coverage for which eligibility is requested. | ||||||||
Summary | false | ||||||||
Comments | 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. | ||||||||
CoverageEligibilityResponse.insurance.coverage | |||||||||
Element Id | CoverageEligibilityResponse.insurance.coverage | ||||||||
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. | ||||||||
Short Display | Insurance information | ||||||||
Cardinality | 1..1 | ||||||||
Type | Reference(Coverage) | ||||||||
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system. | ||||||||
Summary | true | ||||||||
CoverageEligibilityResponse.insurance.inforce | |||||||||
Element Id | CoverageEligibilityResponse.insurance.inforce | ||||||||
Definition | Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates. | ||||||||
Short Display | Coverage inforce indicator | ||||||||
Cardinality | 0..1 | ||||||||
Type | boolean | ||||||||
Requirements | Needed to convey the answer to the eligibility validation request. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.benefitPeriod | |||||||||
Element Id | CoverageEligibilityResponse.insurance.benefitPeriod | ||||||||
Definition | The term of the benefits documented in this response. | ||||||||
Short Display | When the benefits are applicable | ||||||||
Cardinality | 0..1 | ||||||||
Type | Period | ||||||||
Requirements | Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item | ||||||||
Definition | Benefits and optionally current balances, and authorization details by category or service. | ||||||||
Short Display | Benefits and authorization details | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
Invariants |
| ||||||||
CoverageEligibilityResponse.insurance.item.category | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.category | ||||||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||||||
Short Display | Benefit classification | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | Benefit Category Codes (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Needed to convey the category of service or product for which eligibility is sought. | ||||||||
Summary | false | ||||||||
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||||||
CoverageEligibilityResponse.insurance.item.productOrService | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.productOrService | ||||||||
Definition | This contains the product, service, drug or other billing code for the item. | ||||||||
Short Display | Billing, service, product, or drug code | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | USCLS Codes (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Needed to convey the actual service or product for which eligibility is sought. | ||||||||
Alternate Names | Drug Code; Bill Code; Service Code | ||||||||
Summary | false | ||||||||
Comments | Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). | ||||||||
CoverageEligibilityResponse.insurance.item.modifier | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.modifier | ||||||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||||||
Short Display | Product or service billing modifiers | ||||||||
Cardinality | 0..* | ||||||||
Terminology Binding | Modifier type Codes (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | To support provision of the item or to charge an elevated fee. | ||||||||
Summary | false | ||||||||
Comments | 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. | ||||||||
CoverageEligibilityResponse.insurance.item.provider | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.provider | ||||||||
Definition | The practitioner who is eligible for the provision of the product or service. | ||||||||
Short Display | Performing practitioner | ||||||||
Cardinality | 0..1 | ||||||||
Type | Reference(Practitioner | PractitionerRole) | ||||||||
Requirements | Needed to convey the eligible provider. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.excluded | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.excluded | ||||||||
Definition | True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage. | ||||||||
Short Display | Excluded from the plan | ||||||||
Cardinality | 0..1 | ||||||||
Type | boolean | ||||||||
Requirements | Needed to identify items that are specifically excluded from the coverage. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.name | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.name | ||||||||
Definition | A short name or tag for the benefit. | ||||||||
Short Display | Short name for the benefit | ||||||||
Cardinality | 0..1 | ||||||||
Type | string | ||||||||
Requirements | Required to align with other plan names. | ||||||||
Summary | false | ||||||||
Comments | For example: MED01, or DENT2. | ||||||||
CoverageEligibilityResponse.insurance.item.description | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.description | ||||||||
Definition | A richer description of the benefit or services covered. | ||||||||
Short Display | Description of the benefit or services covered | ||||||||
Cardinality | 0..1 | ||||||||
Type | string | ||||||||
Requirements | Needed for human readable reference. | ||||||||
Summary | false | ||||||||
Comments | For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'. | ||||||||
CoverageEligibilityResponse.insurance.item.network | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.network | ||||||||
Definition | Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers. | ||||||||
Short Display | In or out of network | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | Network Type Codes (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Needed as in or out of network providers are treated differently under the coverage. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.unit | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.unit | ||||||||
Definition | Indicates if the benefits apply to an individual or to the family. | ||||||||
Short Display | Individual or family | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | Unit Type Codes (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Needed for the understanding of the benefits. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.term | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.term | ||||||||
Definition | The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. | ||||||||
Short Display | Annual or lifetime | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | Benefit Term Codes (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Needed for the understanding of the benefits. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.benefit | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.benefit | ||||||||
Definition | Benefits used to date. | ||||||||
Short Display | Benefit Summary | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.benefit.type | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.benefit.type | ||||||||
Definition | Classification of benefit being provided. | ||||||||
Short Display | Benefit classification | ||||||||
Cardinality | 1..1 | ||||||||
Terminology Binding | Benefit Type Codes (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Needed to convey the nature of the benefit. | ||||||||
Summary | false | ||||||||
Comments | For example: deductible, visits, benefit amount. | ||||||||
CoverageEligibilityResponse.insurance.item.benefit.allowed[x] | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.benefit.allowed[x] | ||||||||
Definition | The quantity of the benefit which is permitted under the coverage. | ||||||||
Short Display | Benefits allowed | ||||||||
Cardinality | 0..1 | ||||||||
Type | unsignedInt|string|Money | ||||||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||||||
Requirements | Needed to convey the benefits offered under the coverage. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.benefit.used[x] | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.benefit.used[x] | ||||||||
Definition | The quantity of the benefit which have been consumed to date. | ||||||||
Short Display | Benefits used | ||||||||
Cardinality | 0..1 | ||||||||
Type | unsignedInt|string|Money | ||||||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||||||
Requirements | Needed to convey the benefits consumed to date. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.authorizationRequired | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.authorizationRequired | ||||||||
Definition | A boolean flag indicating whether a preauthorization is required prior to actual service delivery. | ||||||||
Short Display | Authorization required flag | ||||||||
Cardinality | 0..1 | ||||||||
Type | boolean | ||||||||
Requirements | Needed to convey that preauthorization is required. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.authorizationSupporting | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.authorizationSupporting | ||||||||
Definition | Codes or comments regarding information or actions associated with the preauthorization. | ||||||||
Short Display | Type of required supporting materials | ||||||||
Cardinality | 0..* | ||||||||
Terminology Binding | CoverageEligibilityResponse Auth Support Codes (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Needed to inform the provider of collateral materials or actions needed for preauthorization. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.insurance.item.authorizationUrl | |||||||||
Element Id | CoverageEligibilityResponse.insurance.item.authorizationUrl | ||||||||
Definition | A web location for obtaining requirements or descriptive information regarding the preauthorization. | ||||||||
Short Display | Preauthorization requirements endpoint | ||||||||
Cardinality | 0..1 | ||||||||
Type | uri | ||||||||
Requirements | Needed to enable insurers to advise providers of informative information. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.preAuthRef | |||||||||
Element Id | CoverageEligibilityResponse.preAuthRef | ||||||||
Definition | A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred. | ||||||||
Short Display | Preauthorization reference | ||||||||
Cardinality | 0..1 | ||||||||
Type | string | ||||||||
Requirements | To provide any preauthorization reference for provider use. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.form | |||||||||
Element Id | CoverageEligibilityResponse.form | ||||||||
Definition | A code for the form to be used for printing the content. | ||||||||
Short Display | Printed form identifier | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | Forms (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Needed to specify the specific form used for producing output for this response. | ||||||||
Summary | false | ||||||||
Comments | May be needed to identify specific jurisdictional forms. | ||||||||
CoverageEligibilityResponse.error | |||||||||
Element Id | CoverageEligibilityResponse.error | ||||||||
Definition | Errors encountered during the processing of the request. | ||||||||
Short Display | Processing errors | ||||||||
Cardinality | 0..* | ||||||||
Requirements | Need to communicate processing issues to the requestor. | ||||||||
Summary | false | ||||||||
CoverageEligibilityResponse.error.code | |||||||||
Element Id | CoverageEligibilityResponse.error.code | ||||||||
Definition | An error code,from a specified code system, which details why the eligibility check could not be performed. | ||||||||
Short Display | Error code detailing processing issues | ||||||||
Cardinality | 1..1 | ||||||||
Terminology Binding | AdjudicationError (Example) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Required to convey processing errors. | ||||||||
Summary | false |