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7.5 Resource EligibilityResponse - Content

This resource maintained by the Financial Management Work Group

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

7.5.1 Scope and Usage

This resource has not yet undergone proper review by FM. At this time, it is to be considered as a draft.

The EligibilityResponse resource provides eligibility and plan details from the processing of an Eligibility resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy details.

Todo

7.5.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityResponse DomainResourceEligibilityResponse resource
... identifier 0..*IdentifierBusiness Identifier
... request 0..1EligibilityRequestClaim reference
... outcome 0..1codecomplete | error
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... organization 0..1OrganizationInsurer
... requestProvider 0..1PractitionerResponsible practitioner
... requestOrganization 0..1OrganizationResponsible organization

XML Template

<EligibilityResponse 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 --></identifier>
 <request><!-- 0..1 Reference(EligibilityRequest) Claim reference --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
</EligibilityResponse>

JSON Template

{doco
  "resourceType" : "EligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "request" : { Reference(EligibilityRequest) }, // Claim reference
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) } // Responsible organization
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityResponse DomainResourceEligibilityResponse resource
... identifier 0..*IdentifierBusiness Identifier
... request 0..1EligibilityRequestClaim reference
... outcome 0..1codecomplete | error
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... organization 0..1OrganizationInsurer
... requestProvider 0..1PractitionerResponsible practitioner
... requestOrganization 0..1OrganizationResponsible organization

XML Template

<EligibilityResponse 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 --></identifier>
 <request><!-- 0..1 Reference(EligibilityRequest) Claim reference --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
</EligibilityResponse>

JSON Template

{doco
  "resourceType" : "EligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "request" : { Reference(EligibilityRequest) }, // Claim reference
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) } // Responsible organization
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.5.2.1 Terminology Bindings

PathDefinitionTypeReference
EligibilityResponse.outcome The outcome of the processing.Requiredhttp://hl7.org/fhir/RS-link
EligibilityResponse.ruleset
EligibilityResponse.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version.Examplehttp://hl7.org/fhir/vs/ruleset

7.5.3 Search Parameters

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

NameTypeDescriptionPaths
identifiertokenThe business identifier of the Explanation of BenefitEligibilityResponse.identifier