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
Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: 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.
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