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

A unique identifier assigned to this coverage eligiblity request.

Allows coverage eligibility requests to be distinguished and referenced.

The status of the resource instance.

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'.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

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.

To indicate the processing actions requested.

The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.

Required to provide context and coverage validation.

The date or dates when the enclosed suite of services were performed or completed.

Required to provide time context for the request.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

The provider which is responsible for the request.

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.

Reference to the original request resource.

Needed to allow the response to be linked to the request.

The outcome of the request processing.

To advise the requestor of an overall processing outcome.

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).

A human readable description of the status of the adjudication.

Provided for user display.

The Insurer who issued the coverage in question and is the author of the response.

Need to identify the author.

Financial instruments for reimbursement for the health care products and services.

There must be at least one coverage for which eligibility is requested.

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.

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.

Required to allow the adjudicator to locate the correct policy and history within their information system.

Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.

Needed to convey the answer to the eligibility validation request.

The term of the benefits documented in this response.

Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

Benefits and optionally current balances, and authorization details by category or service.

Code to identify the general type of benefits under which products and services are provided.

Needed to convey the category of service or product for which eligibility is sought.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

This contains the product, service, drug or other billing code for the item.

Needed to convey the actual service or product for which eligibility is sought.

Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).

Item typification or modifiers codes to convey additional context for the product or service.

To support provision of the item or to charge an elevated fee.

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.

The practitioner who is eligible for the provision of the product or service.

Needed to convey the eligible provider.

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.

Needed to identify items that are specifically excluded from the coverage.

A short name or tag for the benefit.

Required to align with other plan names.

For example: MED01, or DENT2.

A richer description of the benefit or services covered.

Needed for human readable reference.

For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Needed as in or out of network providers are treated differently under the coverage.

Indicates if the benefits apply to an individual or to the family.

Needed for the understanding of the benefits.

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Needed for the understanding of the benefits.

Benefits used to date.

Classification of benefit being provided.

Needed to convey the nature of the benefit.

For example: deductible, visits, benefit amount.

The quantity of the benefit which is permitted under the coverage.

Needed to convey the benefits offered under the coverage.

The quantity of the benefit which have been consumed to date.

Needed to convey the benefits consumed to date.

A boolean flag indicating whether a preauthorization is required prior to actual service delivery.

Needed to convey that preauthorization is required.

Codes or comments regarding information or actions associated with the preauthorization.

Needed to inform the provider of collateral materials or actions needed for preauthorization.

A web location for obtaining requirements or descriptive information regarding the preauthorization.

Needed to enable insurers to advise providers of informative information.

A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.

To provide any preauthorization reference for provider use.

A code for the form to be used for printing the content.

Needed to specify the specific form used for producing output for this response.

May be needed to identify specific jurisdictional forms.

Errors encountered during the processing of the request.

Need to communicate processing issues to the requestor.

An error code,from a specified code system, which details why the eligibility check could not be performed.

Required to convey processing errors.