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Financial Management Work Group | Maturity Level: 4 | Trial Use | Security Category: Patient | Compartments: Patient, Practitioner |
Detailed Descriptions for the elements in the CoverageEligibilityRequest resource.
CoverageEligibilityRequest | |
Element Id | CoverageEligibilityRequest |
Definition | 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. |
Short Display | CoverageEligibilityRequest resource |
Cardinality | 0..* |
Type | DomainResource |
Summary | false |
CoverageEligibilityRequest.identifier | |
Element Id | CoverageEligibilityRequest.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 |
CoverageEligibilityRequest.status | |
Element Id | CoverageEligibilityRequest.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. |
CoverageEligibilityRequest.priority | |
Element Id | CoverageEligibilityRequest.priority |
Definition | When the requestor expects the processor to complete processing. |
Short Display | Desired processing priority |
Cardinality | 0..1 |
Terminology Binding | Process Priority Codes (Example) |
Type | CodeableConcept |
Requirements | Needed to advise the prossesor on the urgency of the request. |
Summary | false |
CoverageEligibilityRequest.purpose | |
Element Id | CoverageEligibilityRequest.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 | Eligibility Request Purpose (Required) |
Type | code |
Requirements | To indicate the processing actions requested. |
Summary | true |
CoverageEligibilityRequest.patient | |
Element Id | CoverageEligibilityRequest.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 |
Comments | 1..1. |
CoverageEligibilityRequest.event | |
Element Id | CoverageEligibilityRequest.event |
Definition | Information code for an event with a corresponding date or period. |
Short Display | Event information |
Cardinality | 0..* |
Summary | false |
CoverageEligibilityRequest.event.type | |
Element Id | CoverageEligibilityRequest.event.type |
Definition | A coded event such as when a service is expected or a card printed. |
Short Display | Specific event |
Cardinality | 1..1 |
Terminology Binding | Dates Type Codes (Example) |
Type | CodeableConcept |
Summary | false |
CoverageEligibilityRequest.event.when[x] | |
Element Id | CoverageEligibilityRequest.event.when[x] |
Definition | A date or period in the past or future indicating when the event occurred or is expectd to occur. |
Short Display | Occurance date or period |
Cardinality | 1..1 |
Type | dateTime|Period |
[x] Note | See Choice of Datatypes for further information about how to use [x] |
Summary | false |
CoverageEligibilityRequest.serviced[x] | |
Element Id | CoverageEligibilityRequest.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 |
CoverageEligibilityRequest.created | |
Element Id | CoverageEligibilityRequest.created |
Definition | The date when this resource was created. |
Short Display | Creation date |
Cardinality | 1..1 |
Type | dateTime |
Requirements | Need to record a timestamp for use by both the recipient and the issuer. |
Summary | true |
CoverageEligibilityRequest.enterer | |
Element Id | CoverageEligibilityRequest.enterer |
Definition | Person who created the request. |
Short Display | Author |
Cardinality | 0..1 |
Type | Reference(Practitioner | PractitionerRole) |
Requirements | Some jurisdictions require the contact information for personnel completing eligibility requests. |
Summary | false |
CoverageEligibilityRequest.provider | |
Element Id | CoverageEligibilityRequest.provider |
Definition | The provider which is responsible for the request. |
Short Display | Party responsible for the request |
Cardinality | 0..1 |
Type | Reference(Practitioner | PractitionerRole | Organization) |
Requirements | Needed to identify the requestor. |
Summary | false |
Comments | Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner. |
CoverageEligibilityRequest.insurer | |
Element Id | CoverageEligibilityRequest.insurer |
Definition | The Insurer who issued the coverage in question and is the recipient of the request. |
Short Display | Coverage issuer |
Cardinality | 1..1 |
Type | Reference(Organization) |
Requirements | Need to identify the recipient. |
Summary | true |
CoverageEligibilityRequest.facility | |
Element Id | CoverageEligibilityRequest.facility |
Definition | Facility where the services are intended to be provided. |
Short Display | Servicing facility |
Cardinality | 0..1 |
Type | Reference(Location) |
Requirements | Insurance adjudication can be dependant on where services were delivered. |
Summary | false |
CoverageEligibilityRequest.supportingInfo | |
Element Id | CoverageEligibilityRequest.supportingInfo |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short Display | Supporting information |
Cardinality | 0..* |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Summary | false |
Comments | Often there are multiple jurisdiction specific valuesets which are required. |
CoverageEligibilityRequest.supportingInfo.sequence | |
Element Id | CoverageEligibilityRequest.supportingInfo.sequence |
Definition | A number to uniquely identify supporting information entries. |
Short Display | Information instance identifier |
Cardinality | 1..1 |
Type | positiveInt |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Summary | false |
CoverageEligibilityRequest.supportingInfo.information | |
Element Id | CoverageEligibilityRequest.supportingInfo.information |
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. |
Short Display | Data to be provided |
Cardinality | 1..1 |
Type | Reference(Any) |
Requirements | To convey the data content to be provided when the information is more than a simple code or period. |
Summary | false |
Comments | Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident. |
CoverageEligibilityRequest.supportingInfo.appliesToAll | |
Element Id | CoverageEligibilityRequest.supportingInfo.appliesToAll |
Definition | The supporting materials are applicable for all detail items, product/servce categories and specific billing codes. |
Short Display | Applies to all items |
Cardinality | 0..1 |
Type | boolean |
Requirements | Needed to convey that the information is universal to the request. |
Summary | false |
CoverageEligibilityRequest.insurance | |
Element Id | CoverageEligibilityRequest.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. |
CoverageEligibilityRequest.insurance.focal | |
Element Id | CoverageEligibilityRequest.insurance.focal |
Definition | A flag to indicate that this Coverage is to be used for evaluation of this request when set to true. |
Short Display | Applicable coverage |
Cardinality | 0..1 |
Type | boolean |
Requirements | To identify which coverage in the list is being used to evaluate this request. |
Summary | false |
Comments | A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for evaluating this request. Other requests would be created to request evaluation against the other listed policies. |
CoverageEligibilityRequest.insurance.coverage | |
Element Id | CoverageEligibilityRequest.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 | false |
CoverageEligibilityRequest.insurance.businessArrangement | |
Element Id | CoverageEligibilityRequest.insurance.businessArrangement |
Definition | A business agreement number established between the provider and the insurer for special business processing purposes. |
Short Display | Additional provider contract number |
Cardinality | 0..1 |
Type | string |
Requirements | Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication. |
Summary | false |
CoverageEligibilityRequest.item | |
Element Id | CoverageEligibilityRequest.item |
Definition | Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor. |
Short Display | Item to be evaluated for eligibiity |
Cardinality | 0..* |
Requirements | The items to be processed for the request. |
Summary | false |
CoverageEligibilityRequest.item.supportingInfoSequence | |
Element Id | CoverageEligibilityRequest.item.supportingInfoSequence |
Definition | Exceptions, special conditions and supporting information applicable for this service or product line. |
Short Display | Applicable exception or supporting information |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Needed to support or inform the consideration for eligibility. |
Summary | false |
CoverageEligibilityRequest.item.category | |
Element Id | CoverageEligibilityRequest.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. |
CoverageEligibilityRequest.item.productOrService | |
Element Id | CoverageEligibilityRequest.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. |
Summary | false |
Comments | Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). |
CoverageEligibilityRequest.item.modifier | |
Element Id | CoverageEligibilityRequest.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. |
CoverageEligibilityRequest.item.provider | |
Element Id | CoverageEligibilityRequest.item.provider |
Definition | The practitioner who is responsible for the product or service to be rendered to the patient. |
Short Display | Perfoming practitioner |
Cardinality | 0..1 |
Type | Reference(Practitioner | PractitionerRole) |
Requirements | Needed to support the evaluation of the eligibility. |
Summary | false |
CoverageEligibilityRequest.item.quantity | |
Element Id | CoverageEligibilityRequest.item.quantity |
Definition | The number of repetitions of a service or product. |
Short Display | Count of products or services |
Cardinality | 0..1 |
Type | SimpleQuantity |
Requirements | Required when the product or service code does not convey the quantity provided. |
Summary | false |
CoverageEligibilityRequest.item.unitPrice | |
Element Id | CoverageEligibilityRequest.item.unitPrice |
Definition | The amount charged to the patient by the provider for a single unit. |
Short Display | Fee, charge or cost per item |
Cardinality | 0..1 |
Type | Money |
Requirements | Needed to support the evaluation of the eligibility. |
Summary | false |
CoverageEligibilityRequest.item.facility | |
Element Id | CoverageEligibilityRequest.item.facility |
Definition | Facility where the services will be provided. |
Short Display | Servicing facility |
Cardinality | 0..1 |
Type | Reference(Location | Organization) |
Requirements | Needed to support the evaluation of the eligibility. |
Summary | false |
CoverageEligibilityRequest.item.diagnosis | |
Element Id | CoverageEligibilityRequest.item.diagnosis |
Definition | Patient diagnosis for which care is sought. |
Short Display | Applicable diagnosis |
Cardinality | 0..* |
Requirements | Needed to support the evaluation of the eligibility. |
Summary | false |
CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | |
Element Id | CoverageEligibilityRequest.item.diagnosis.diagnosis[x] |
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition. |
Short Display | Nature of illness or problem |
Cardinality | 0..1 |
Terminology Binding | ICD-10 Codes (Example) |
Type | CodeableConcept|Reference(Condition) |
[x] Note | See Choice of Datatypes for further information about how to use [x] |
Requirements | Provides health context for the evaluation of the products and/or services. |
Summary | false |
CoverageEligibilityRequest.item.detail | |
Element Id | CoverageEligibilityRequest.item.detail |
Definition | The plan/proposal/order describing the proposed service in detail. |
Short Display | Product or service details |
Cardinality | 0..* |
Type | Reference(Any) |
Requirements | Needed to provide complex service proposal such as a Device or a plan. |
Summary | false |