Release 5 Ballot

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

13.3 Resource CoverageEligibilityResponse - Content

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

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

13.3.1 Scope and Usage

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

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

13.3.1.1 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.

13.3.2 Boundaries and Relationships

CoverageEligibilityResponse should be used to respond to a request on whether the patient's coverage is inforce, whether it is valid at this or a specified date, or to report the benefit details or preauthorization requirements associated with a coverage.

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 CoverageEligibilityRequest should be used instead.

The ClaimResponse resource is an insurer's adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages.

For reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used .

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 CoverageEligibilityResponse.

The eClaim domain includes a number of related resources

CoverageEligibilityResponse 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.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
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.
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.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.

13.3.3 References to this Resource

13.3.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse TUDomainResourceCoverageEligibilityResponse resource

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for coverage eligiblity request

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
EligibilityResponsePurpose (Required)

... serviced[x] 0..1Estimated date or dates of service
.... servicedDatedate
.... servicedPeriodPeriod
... created Σ1..1dateTimeResponse creation date
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the request
... request Σ1..1Reference(CoverageEligibilityRequest)Eligibility request reference
... outcome Σ1..1codequeued | complete | error | partial
EligibilityOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer Σ1..1Reference(Organization)Coverage issuer
... insurance 0..*BackboneElementPatient insurance information

.... coverage Σ1..1Reference(Coverage)Insurance information
.... inforce 0..1booleanCoverage inforce indicator
.... benefitPeriod 0..1PeriodWhen the benefits are applicable
.... item C0..*BackboneElementBenefits and authorization details
+ Rule: SHALL contain a category or a billcode but not both.

..... 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)Performing practitioner
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit or services covered
..... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
..... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
..... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
..... benefit 0..*BackboneElementBenefit Summary

...... type 1..1CodeableConceptBenefit classification
Benefit Type Codes (Example)
...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedStringstring
....... usedMoneyMoney
..... authorizationRequired 0..1booleanAuthorization required flag
..... authorizationSupporting 0..*CodeableConceptType of required supporting materials
CoverageEligibilityResponse Auth Support Codes (Example)

..... authorizationUrl 0..1uriPreauthorization requirements endpoint
... preAuthRef 0..1stringPreauthorization reference
... form 0..1CodeableConceptPrinted form identifier
Forms (Example)
... error 0..*BackboneElementProcessing errors

.... code 1..1CodeableConceptError code detailing processing issues
AdjudicationError (Example)

doco Documentation for this format

See the Extensions for this resource

UML Diagram (Legend)

CoverageEligibilityResponse (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] « null (Strength=Required)FinancialResourceStatusCodes! »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..*] « null (Strength=Required)EligibilityResponsePurpose! »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 this resource was createdcreated : dateTime [1..1]The provider which is responsible for the requestrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »Reference to the original request resourcerequest : Reference [1..1] « CoverageEligibilityRequest »The outcome of the request processingoutcome : code [1..1] « null (Strength=Required)EligibilityOutcome! »A human readable description of the status of the adjudicationdisposition : string [0..1]The Insurer who issued the coverage in question and is the author of the responseinsurer : Reference [1..1] « Organization »A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurredpreAuthRef : string [0..1]A code for the form to be used for printing the contentform : CodeableConcept [0..1] « null (Strength=Example)Form ?? »InsuranceReference 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 »Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service datesinforce : boolean [0..1]The term of the benefits documented in this responsebenefitPeriod : Period [0..1]ItemsCode to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »This contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The practitioner who is eligible for the provision of the product or serviceprovider : Reference [0..1] « Practitioner|PractitionerRole »True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefitname : string [0..1]A richer description of the benefit or services covereddescription : string [0..1]Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providersnetwork : CodeableConcept [0..1] « null (Strength=Example)NetworkTypeCodes?? »Indicates if the benefits apply to an individual or to the familyunit : CodeableConcept [0..1] « null (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « null (Strength=Example)BenefitTermCodes?? »A boolean flag indicating whether a preauthorization is required prior to actual service deliveryauthorizationRequired : boolean [0..1]Codes or comments regarding information or actions associated with the preauthorizationauthorizationSupporting : CodeableConcept [0..*] « null (Strength=Example) CoverageEligibilityResponseAu...?? »A web location for obtaining requirements or descriptive information regarding the preauthorizationauthorizationUrl : uri [0..1]BenefitClassification of benefit being providedtype : CodeableConcept [1..1] « null (Strength=Example)BenefitTypeCodes?? »The quantity of the benefit which is permitted under the coverageallowed[x] : DataType [0..1] « unsignedInt|string|Money »The quantity of the benefit which have been consumed to dateused[x] : DataType [0..1] « unsignedInt|string|Money »ErrorsAn error code,from a specified code system, which details why the eligibility check could not be performedcode : CodeableConcept [1..1] « null (Strength=Example)Adjudication Error ?? »Benefits used to datebenefit[0..*]Benefits and optionally current balances, and authorization details by category or serviceitem[0..*]Financial instruments for reimbursement for the health care products and servicesinsurance[0..*]Errors encountered during the processing of the requesterror[0..*]

XML Template

<CoverageEligibilityResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <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 Response creation date -->
 <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></requestor>
 <request><!-- 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <insurance>  <!-- 0..* Patient insurance information -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
  <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
  <item>  <!-- 0..* Benefits and authorization details -->
   <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) Performing practitioner --></provider>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <benefit>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Benefit classification --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|string|Money Benefits used --></used[x]>
   </benefit>
   <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag -->
   <authorizationSupporting><!-- 0..* CodeableConcept Type of required supporting materials --></authorizationSupporting>
   <authorizationUrl value="[uri]"/><!-- 0..1 Preauthorization requirements endpoint -->
  </item>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <form><!-- 0..1 CodeableConcept Printed form identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</CoverageEligibilityResponse>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "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!  Response creation date
  "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request
  "request" : { Reference(CoverageEligibilityRequest) }, // R!  Eligibility request reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "insurance" : [{ // Patient insurance information
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "inforce" : <boolean>, // Coverage inforce indicator
    "benefitPeriod" : { Period }, // When the benefits are applicable
    "item" : [{ // Benefits and authorization details
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
      "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "benefit" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Benefit classification
        // allowed[x]: Benefits allowed. One of these 3:
        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 3:
        "usedUnsignedInt" : "<unsignedInt>",
        "usedString" : "<string>",
        "usedMoney" : { Money }
      }],
      "authorizationRequired" : <boolean>, // Authorization required flag
      "authorizationSupporting" : [{ CodeableConcept }], // Type of required supporting materials
      "authorizationUrl" : "<uri>" // Preauthorization requirements endpoint
    }]
  }],
  "preAuthRef" : "<string>", // Preauthorization reference
  "form" : { CodeableConcept }, // Printed form identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle Template

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CoverageEligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityResponse.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityResponse.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityResponse.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityResponse.servicedDate [ date ]
    fhir:CoverageEligibilityResponse.servicedPeriod [ Period ]
  fhir:CoverageEligibilityResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:CoverageEligibilityResponse.requestor [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the request
  fhir:CoverageEligibilityResponse.request [ Reference(CoverageEligibilityRequest) ]; # 1..1 Eligibility request reference
  fhir:CoverageEligibilityResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:CoverageEligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:CoverageEligibilityResponse.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityResponse.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityResponse.insurance.inforce [ boolean ]; # 0..1 Coverage inforce indicator
    fhir:CoverageEligibilityResponse.insurance.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
    fhir:CoverageEligibilityResponse.insurance.item [ # 0..* Benefits and authorization details
      fhir:CoverageEligibilityResponse.insurance.item.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:CoverageEligibilityResponse.insurance.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:CoverageEligibilityResponse.insurance.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
      fhir:CoverageEligibilityResponse.insurance.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Performing practitioner
      fhir:CoverageEligibilityResponse.insurance.item.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:CoverageEligibilityResponse.insurance.item.name [ string ]; # 0..1 Short name for the benefit
      fhir:CoverageEligibilityResponse.insurance.item.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:CoverageEligibilityResponse.insurance.item.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:CoverageEligibilityResponse.insurance.item.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:CoverageEligibilityResponse.insurance.item.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:CoverageEligibilityResponse.insurance.item.benefit [ # 0..* Benefit Summary
        fhir:CoverageEligibilityResponse.insurance.item.benefit.type [ CodeableConcept ]; # 1..1 Benefit classification
        # CoverageEligibilityResponse.insurance.item.benefit.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedMoney [ Money ]
        # CoverageEligibilityResponse.insurance.item.benefit.used[x] : 0..1 Benefits used. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedMoney [ Money ]
      ], ...;
      fhir:CoverageEligibilityResponse.insurance.item.authorizationRequired [ boolean ]; # 0..1 Authorization required flag
      fhir:CoverageEligibilityResponse.insurance.item.authorizationSupporting [ CodeableConcept ], ... ; # 0..* Type of required supporting materials
      fhir:CoverageEligibilityResponse.insurance.item.authorizationUrl [ uri ]; # 0..1 Preauthorization requirements endpoint
    ], ...;
  ], ...;
  fhir:CoverageEligibilityResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:CoverageEligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:CoverageEligibilityResponse.error [ # 0..* Processing errors
    fhir:CoverageEligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since R4

CoverageEligibilityResponse
CoverageEligibilityResponse.outcome
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/eligibility-outcome|5.0.0-ballot
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/eligibility-outcome|5.0.0-ballot

See the Full Difference for further information

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse TUDomainResourceCoverageEligibilityResponse resource

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for coverage eligiblity request

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
EligibilityResponsePurpose (Required)

... serviced[x] 0..1Estimated date or dates of service
.... servicedDatedate
.... servicedPeriodPeriod
... created Σ1..1dateTimeResponse creation date
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the request
... request Σ1..1Reference(CoverageEligibilityRequest)Eligibility request reference
... outcome Σ1..1codequeued | complete | error | partial
EligibilityOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer Σ1..1Reference(Organization)Coverage issuer
... insurance 0..*BackboneElementPatient insurance information

.... coverage Σ1..1Reference(Coverage)Insurance information
.... inforce 0..1booleanCoverage inforce indicator
.... benefitPeriod 0..1PeriodWhen the benefits are applicable
.... item C0..*BackboneElementBenefits and authorization details
+ Rule: SHALL contain a category or a billcode but not both.

..... 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)Performing practitioner
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit or services covered
..... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
..... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
..... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
..... benefit 0..*BackboneElementBenefit Summary

...... type 1..1CodeableConceptBenefit classification
Benefit Type Codes (Example)
...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedStringstring
....... usedMoneyMoney
..... authorizationRequired 0..1booleanAuthorization required flag
..... authorizationSupporting 0..*CodeableConceptType of required supporting materials
CoverageEligibilityResponse Auth Support Codes (Example)

..... authorizationUrl 0..1uriPreauthorization requirements endpoint
... preAuthRef 0..1stringPreauthorization reference
... form 0..1CodeableConceptPrinted form identifier
Forms (Example)
... error 0..*BackboneElementProcessing errors

.... code 1..1CodeableConceptError code detailing processing issues
AdjudicationError (Example)

doco Documentation for this format

See the Extensions for this resource

UML Diagram (Legend)

CoverageEligibilityResponse (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] « null (Strength=Required)FinancialResourceStatusCodes! »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..*] « null (Strength=Required)EligibilityResponsePurpose! »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 this resource was createdcreated : dateTime [1..1]The provider which is responsible for the requestrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »Reference to the original request resourcerequest : Reference [1..1] « CoverageEligibilityRequest »The outcome of the request processingoutcome : code [1..1] « null (Strength=Required)EligibilityOutcome! »A human readable description of the status of the adjudicationdisposition : string [0..1]The Insurer who issued the coverage in question and is the author of the responseinsurer : Reference [1..1] « Organization »A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurredpreAuthRef : string [0..1]A code for the form to be used for printing the contentform : CodeableConcept [0..1] « null (Strength=Example)Form ?? »InsuranceReference 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 »Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service datesinforce : boolean [0..1]The term of the benefits documented in this responsebenefitPeriod : Period [0..1]ItemsCode to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »This contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The practitioner who is eligible for the provision of the product or serviceprovider : Reference [0..1] « Practitioner|PractitionerRole »True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefitname : string [0..1]A richer description of the benefit or services covereddescription : string [0..1]Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providersnetwork : CodeableConcept [0..1] « null (Strength=Example)NetworkTypeCodes?? »Indicates if the benefits apply to an individual or to the familyunit : CodeableConcept [0..1] « null (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « null (Strength=Example)BenefitTermCodes?? »A boolean flag indicating whether a preauthorization is required prior to actual service deliveryauthorizationRequired : boolean [0..1]Codes or comments regarding information or actions associated with the preauthorizationauthorizationSupporting : CodeableConcept [0..*] « null (Strength=Example) CoverageEligibilityResponseAu...?? »A web location for obtaining requirements or descriptive information regarding the preauthorizationauthorizationUrl : uri [0..1]BenefitClassification of benefit being providedtype : CodeableConcept [1..1] « null (Strength=Example)BenefitTypeCodes?? »The quantity of the benefit which is permitted under the coverageallowed[x] : DataType [0..1] « unsignedInt|string|Money »The quantity of the benefit which have been consumed to dateused[x] : DataType [0..1] « unsignedInt|string|Money »ErrorsAn error code,from a specified code system, which details why the eligibility check could not be performedcode : CodeableConcept [1..1] « null (Strength=Example)Adjudication Error ?? »Benefits used to datebenefit[0..*]Benefits and optionally current balances, and authorization details by category or serviceitem[0..*]Financial instruments for reimbursement for the health care products and servicesinsurance[0..*]Errors encountered during the processing of the requesterror[0..*]

XML Template

<CoverageEligibilityResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <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 Response creation date -->
 <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></requestor>
 <request><!-- 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <insurance>  <!-- 0..* Patient insurance information -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
  <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
  <item>  <!-- 0..* Benefits and authorization details -->
   <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) Performing practitioner --></provider>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <benefit>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Benefit classification --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|string|Money Benefits used --></used[x]>
   </benefit>
   <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag -->
   <authorizationSupporting><!-- 0..* CodeableConcept Type of required supporting materials --></authorizationSupporting>
   <authorizationUrl value="[uri]"/><!-- 0..1 Preauthorization requirements endpoint -->
  </item>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <form><!-- 0..1 CodeableConcept Printed form identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</CoverageEligibilityResponse>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "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!  Response creation date
  "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request
  "request" : { Reference(CoverageEligibilityRequest) }, // R!  Eligibility request reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "insurance" : [{ // Patient insurance information
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "inforce" : <boolean>, // Coverage inforce indicator
    "benefitPeriod" : { Period }, // When the benefits are applicable
    "item" : [{ // Benefits and authorization details
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
      "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "benefit" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Benefit classification
        // allowed[x]: Benefits allowed. One of these 3:
        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 3:
        "usedUnsignedInt" : "<unsignedInt>",
        "usedString" : "<string>",
        "usedMoney" : { Money }
      }],
      "authorizationRequired" : <boolean>, // Authorization required flag
      "authorizationSupporting" : [{ CodeableConcept }], // Type of required supporting materials
      "authorizationUrl" : "<uri>" // Preauthorization requirements endpoint
    }]
  }],
  "preAuthRef" : "<string>", // Preauthorization reference
  "form" : { CodeableConcept }, // Printed form identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle Template

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CoverageEligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityResponse.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityResponse.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityResponse.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityResponse.servicedDate [ date ]
    fhir:CoverageEligibilityResponse.servicedPeriod [ Period ]
  fhir:CoverageEligibilityResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:CoverageEligibilityResponse.requestor [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the request
  fhir:CoverageEligibilityResponse.request [ Reference(CoverageEligibilityRequest) ]; # 1..1 Eligibility request reference
  fhir:CoverageEligibilityResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:CoverageEligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:CoverageEligibilityResponse.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityResponse.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityResponse.insurance.inforce [ boolean ]; # 0..1 Coverage inforce indicator
    fhir:CoverageEligibilityResponse.insurance.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
    fhir:CoverageEligibilityResponse.insurance.item [ # 0..* Benefits and authorization details
      fhir:CoverageEligibilityResponse.insurance.item.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:CoverageEligibilityResponse.insurance.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:CoverageEligibilityResponse.insurance.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
      fhir:CoverageEligibilityResponse.insurance.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Performing practitioner
      fhir:CoverageEligibilityResponse.insurance.item.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:CoverageEligibilityResponse.insurance.item.name [ string ]; # 0..1 Short name for the benefit
      fhir:CoverageEligibilityResponse.insurance.item.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:CoverageEligibilityResponse.insurance.item.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:CoverageEligibilityResponse.insurance.item.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:CoverageEligibilityResponse.insurance.item.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:CoverageEligibilityResponse.insurance.item.benefit [ # 0..* Benefit Summary
        fhir:CoverageEligibilityResponse.insurance.item.benefit.type [ CodeableConcept ]; # 1..1 Benefit classification
        # CoverageEligibilityResponse.insurance.item.benefit.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedMoney [ Money ]
        # CoverageEligibilityResponse.insurance.item.benefit.used[x] : 0..1 Benefits used. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedMoney [ Money ]
      ], ...;
      fhir:CoverageEligibilityResponse.insurance.item.authorizationRequired [ boolean ]; # 0..1 Authorization required flag
      fhir:CoverageEligibilityResponse.insurance.item.authorizationSupporting [ CodeableConcept ], ... ; # 0..* Type of required supporting materials
      fhir:CoverageEligibilityResponse.insurance.item.authorizationUrl [ uri ]; # 0..1 Preauthorization requirements endpoint
    ], ...;
  ], ...;
  fhir:CoverageEligibilityResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:CoverageEligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:CoverageEligibilityResponse.error [ # 0..* Processing errors
    fhir:CoverageEligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since Release 4

CoverageEligibilityResponse
CoverageEligibilityResponse.outcome
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/eligibility-outcome|5.0.0-ballot
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/eligibility-outcome|5.0.0-ballot

See the Full Difference for further information

This analysis is available as XML or JSON.

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

13.3.4.1 Terminology Bindings

PathDefinitionTypeReference
CoverageEligibilityResponse.status

This value set includes Status codes.

RequiredFinancialResourceStatusCodes
CoverageEligibilityResponse.purpose

A code specifying the types of information being requested.

RequiredEligibilityResponsePurpose
CoverageEligibilityResponse.outcome

The outcome of the processing.

RequiredEligibilityOutcome
CoverageEligibilityResponse.insurance.item.category

This value set includes examples of Benefit Category codes.

ExampleBenefitCategoryCodes
CoverageEligibilityResponse.insurance.item.productOrService

This value set includes a smattering of USCLS codes.

ExampleUSCLSCodes
CoverageEligibilityResponse.insurance.item.modifier

This value set includes sample Modifier type codes.

ExampleModifierTypeCodes
CoverageEligibilityResponse.insurance.item.network

This value set includes a smattering of Network type codes.

ExampleNetworkTypeCodes
CoverageEligibilityResponse.insurance.item.unit

This value set includes a smattering of Unit type codes.

ExampleUnitTypeCodes
CoverageEligibilityResponse.insurance.item.term

This value set includes a smattering of Benefit Term codes.

ExampleBenefitTermCodes
CoverageEligibilityResponse.insurance.item.benefit.type

This value set includes a smattering of Benefit type codes.

ExampleBenefitTypeCodes
CoverageEligibilityResponse.insurance.item.authorizationSupporting

This value set includes CoverageEligibilityResponse Auth Support codes.

ExampleCoverageEligibilityResponseAuthSupportCodes
CoverageEligibilityResponse.form

This value set includes a sample set of Forms codes.

ExampleForm Codes
CoverageEligibilityResponse.error.code

This value set includes a smattering of adjudication codes.

ExampleAdjudication Error Codes

13.3.4.2 Constraints

UniqueKeyLevelLocationDescriptionExpression
img ces-1Rule CoverageEligibilityResponse.insurance.itemSHALL contain a category or a billcode but not both.category.exists() xor productOrService.exists()

13.3.5 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 dateCoverageEligibilityResponse.created
disposition NstringThe contents of the disposition messageCoverageEligibilityResponse.disposition
identifiertokenThe business identifierCoverageEligibilityResponse.identifier
insurerreferenceThe organization which generated this resourceCoverageEligibilityResponse.insurer
(Organization)
outcome NtokenThe processing outcomeCoverageEligibilityResponse.outcome
patientreferenceThe reference to the patientCoverageEligibilityResponse.patient
(Patient)
requestreferenceThe EligibilityRequest referenceCoverageEligibilityResponse.request
(CoverageEligibilityRequest)
requestorreferenceThe EligibilityRequest providerCoverageEligibilityResponse.requestor
(Practitioner, Organization, PractitionerRole)
status NtokenThe EligibilityRequest statusCoverageEligibilityResponse.status