Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

Example CoverageEligibilityResponse/E2502 (JSON)

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Patient, Practitioner

Raw JSON (canonical form + also see JSON Format Specification)

General Person Primary Coverage with Benefit Details and new insurance

{
  "resourceType" : "CoverageEligibilityResponse",
  "id" : "E2502",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the CoverageEligibilityResponse.</div>"
  },
  "contained" : [{
    "resourceType" : "Coverage",
    "id" : "coverage-1",
    "identifier" : [{
      "system" : "http://benefitsinc.com/certificate",
      "value" : "12345"
    }],
    "status" : "active",
    "kind" : "insurance",
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code" : "EHCPOL"
      }]
    },
    "subscriber" : {
      "reference" : "Patient/f201"
    },
    "beneficiary" : {
      "reference" : "Patient/f201"
    },
    "dependent" : "1",
    "relationship" : {
      "coding" : [{
        "code" : "self"
      }]
    },
    "insurer" : {
      "identifier" : {
        "system" : "http://www.bindb.com/bin",
        "value" : "123456"
      }
    },
    "class" : [{
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
          "code" : "EHCPOL"
        }]
      },
      "value" : {
        "value" : "CBI35"
      },
      "name" : "Corporate Baker's Inc. Plan#35"
    },
    {
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
          "code" : "subplan"
        }]
      },
      "value" : {
        "value" : "123"
      },
      "name" : "Trainee Part-time Benefits"
    },
    {
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
          "code" : "sequence"
        }]
      },
      "value" : {
        "value" : "1"
      }
    }]
  }],
  "identifier" : [{
    "system" : "http://www.BenefitsInc.com/fhir/coverageeligibilityresponse",
    "value" : "8812342"
  }],
  "status" : "active",
  "purpose" : ["validation",
  "benefits"],
  "patient" : {
    "reference" : "Patient/f201"
  },
  "created" : "2014-09-16",
  "requestor" : {
    "identifier" : {
      "system" : "http://national.org/clinic",
      "value" : "OR1234"
    }
  },
  "request" : {
    "reference" : "http://www.BenefitsInc.com/fhir/coverageeligibilityrequest/225476332405"
  },
  "outcome" : "complete",
  "disposition" : "Policy is currently in-force.",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "insurance" : [{
    "coverage" : {
      "reference" : "#coverage-1"
    },
    "inforce" : true,
    "item" : [{
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
          "code" : "30",
          "display" : "Health Benefit Plan Coverage"
        }]
      },
      "network" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
          "code" : "in"
        }]
      },
      "unit" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
          "code" : "individual"
        }]
      },
      "term" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
          "code" : "annual"
        }]
      },
      "benefit" : [{
        "type" : {
          "coding" : [{
            "code" : "benefit"
          }]
        },
        "allowedMoney" : {
          "value" : 500000,
          "currency" : "USD"
        },
        "usedMoney" : {
          "value" : 3748.00,
          "currency" : "USD"
        }
      },
      {
        "type" : {
          "coding" : [{
            "code" : "copay-maximum"
          }]
        },
        "allowedMoney" : {
          "value" : 100,
          "currency" : "USD"
        }
      },
      {
        "type" : {
          "coding" : [{
            "code" : "copay-percent"
          }]
        },
        "allowedUnsignedInt" : 20
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
          "code" : "69",
          "display" : "Maternity"
        }]
      },
      "network" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
          "code" : "in"
        }]
      },
      "unit" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
          "code" : "individual"
        }]
      },
      "term" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
          "code" : "annual"
        }]
      },
      "benefit" : [{
        "type" : {
          "coding" : [{
            "code" : "benefit"
          }]
        },
        "allowedMoney" : {
          "value" : 15000,
          "currency" : "USD"
        }
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
          "code" : "F3",
          "display" : "Dental Coverage"
        }]
      },
      "network" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
          "code" : "in"
        }]
      },
      "unit" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
          "code" : "individual"
        }]
      },
      "term" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
          "code" : "annual"
        }]
      },
      "benefit" : [{
        "type" : {
          "coding" : [{
            "code" : "benefit"
          }]
        },
        "allowedMoney" : {
          "value" : 2000,
          "currency" : "USD"
        }
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
          "code" : "F6",
          "display" : "Vision Coverage"
        }]
      },
      "excluded" : true,
      "name" : "Vision",
      "description" : "Vision products and services such as exams, glasses and contact lenses."
    }]
  }],
  "form" : {
    "coding" : [{
      "system" : "http://national.org/form",
      "code" : "ELRSP/2017/01"
    }]
  }
}

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.