FHIR Release 3 (STU)

This page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R3 R2

13.2 Resource EligibilityRequest - Content

Financial Management Work GroupMaturity Level: 2 Trial UseCompartments: Patient, Practitioner

The EligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an EligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.

13.2.1 Scope and Usage

The EligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an Eligibility Response, with information regarding whether the stated coverage is valid and in-force, and potentially the amount of coverage which may be available to any services classes identified in this request. Todo

This resource is referenced by eligibilityresponse

13.2.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityRequest DomainResourceDetermine insurance validity and scope of coverage
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... provider 0..1Reference(Practitioner)Responsible practitioner
... organization 0..1Reference(Organization)Responsible organization
... insurer 0..1Reference(Organization)Target
... facility 0..1Reference(Location)Servicing Facility
... coverage 0..1Reference(Coverage)Insurance or medical plan
... businessArrangement 0..1stringBusiness agreement
... benefitCategory 0..1CodeableConceptType of services covered
Benefit Category Codes (Example)
... benefitSubCategory 0..1CodeableConceptDetailed services covered within the type
Benefit SubCategory Codes (Example)

doco Documentation for this format

UML Diagram (Legend)

EligibilityRequest (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Process Priority ?? Patient Resourcepatient : Reference [0..1] Patient The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] date|Period The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] Practitioner The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] Practitioner The organization which is responsible for the services rendered to the patientorganization : Reference [0..1] Organization The Insurer who is target of the requestinsurer : Reference [0..1] Organization Facility where the services were providedfacility : Reference [0..1] Location Financial instrument by which payment information for health carecoverage : Reference [0..1] Coverage The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]Dental, Vision, Medical, Pharmacy, Rehab etcbenefitCategory : CodeableConcept [0..1] Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? Dental: basic, major, ortho; Vision exam, glasses, contacts; etcbenefitSubCategory : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ??

XML Template

<EligibilityRequest 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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <benefitCategory><!-- 0..1 CodeableConcept Type of services covered --></benefitCategory>
 <benefitSubCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></benefitSubCategory>
</EligibilityRequest>

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:EligibilityRequest;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityRequest.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:EligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # EligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2
    fhir:EligibilityRequest.servicedDate [ date ]
    fhir:EligibilityRequest.servicedPeriod [ Period ]
  fhir:EligibilityRequest.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityRequest.enterer [ Reference(Practitioner) ]; # 0..1 Author
  fhir:EligibilityRequest.provider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:EligibilityRequest.organization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:EligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:EligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:EligibilityRequest.coverage [ Reference(Coverage) ]; # 0..1 Insurance or medical plan
  fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement
  fhir:EligibilityRequest.benefitCategory [ CodeableConcept ]; # 0..1 Type of services covered
  fhir:EligibilityRequest.benefitSubCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
]

Changes since DSTU2

EligibilityRequest
EligibilityRequest.status
  • Added Element
EligibilityRequest.priority
  • Added Element
EligibilityRequest.patient
  • Added Element
EligibilityRequest.serviced[x]
  • Added Element
EligibilityRequest.enterer
  • Added Element
EligibilityRequest.insurer
  • Added Element
EligibilityRequest.facility
  • Added Element
EligibilityRequest.coverage
  • Added Element
EligibilityRequest.businessArrangement
  • Added Element
EligibilityRequest.benefitCategory
  • Added Element
EligibilityRequest.benefitSubCategory
  • Added Element
EligibilityRequest.ruleset
  • deleted
EligibilityRequest.originalRuleset
  • deleted
EligibilityRequest.target
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityRequest DomainResourceDetermine insurance validity and scope of coverage
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... provider 0..1Reference(Practitioner)Responsible practitioner
... organization 0..1Reference(Organization)Responsible organization
... insurer 0..1Reference(Organization)Target
... facility 0..1Reference(Location)Servicing Facility
... coverage 0..1Reference(Coverage)Insurance or medical plan
... businessArrangement 0..1stringBusiness agreement
... benefitCategory 0..1CodeableConceptType of services covered
Benefit Category Codes (Example)
... benefitSubCategory 0..1CodeableConceptDetailed services covered within the type
Benefit SubCategory Codes (Example)

doco Documentation for this format

UML Diagram (Legend)

EligibilityRequest (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Process Priority ?? Patient Resourcepatient : Reference [0..1] Patient The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] date|Period The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] Practitioner The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] Practitioner The organization which is responsible for the services rendered to the patientorganization : Reference [0..1] Organization The Insurer who is target of the requestinsurer : Reference [0..1] Organization Facility where the services were providedfacility : Reference [0..1] Location Financial instrument by which payment information for health carecoverage : Reference [0..1] Coverage The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]Dental, Vision, Medical, Pharmacy, Rehab etcbenefitCategory : CodeableConcept [0..1] Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? Dental: basic, major, ortho; Vision exam, glasses, contacts; etcbenefitSubCategory : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ??

XML Template

<EligibilityRequest 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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <benefitCategory><!-- 0..1 CodeableConcept Type of services covered --></benefitCategory>
 <benefitSubCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></benefitSubCategory>
</EligibilityRequest>

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:EligibilityRequest;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityRequest.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:EligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # EligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2
    fhir:EligibilityRequest.servicedDate [ date ]
    fhir:EligibilityRequest.servicedPeriod [ Period ]
  fhir:EligibilityRequest.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityRequest.enterer [ Reference(Practitioner) ]; # 0..1 Author
  fhir:EligibilityRequest.provider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:EligibilityRequest.organization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:EligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:EligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:EligibilityRequest.coverage [ Reference(Coverage) ]; # 0..1 Insurance or medical plan
  fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement
  fhir:EligibilityRequest.benefitCategory [ CodeableConcept ]; # 0..1 Type of services covered
  fhir:EligibilityRequest.benefitSubCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
]

Changes since DSTU2

EligibilityRequest
EligibilityRequest.status
  • Added Element
EligibilityRequest.priority
  • Added Element
EligibilityRequest.patient
  • Added Element
EligibilityRequest.serviced[x]
  • Added Element
EligibilityRequest.enterer
  • Added Element
EligibilityRequest.insurer
  • Added Element
EligibilityRequest.facility
  • Added Element
EligibilityRequest.coverage
  • Added Element
EligibilityRequest.businessArrangement
  • Added Element
EligibilityRequest.benefitCategory
  • Added Element
EligibilityRequest.benefitSubCategory
  • Added Element
EligibilityRequest.ruleset
  • deleted
EligibilityRequest.originalRuleset
  • deleted
EligibilityRequest.target
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle)

13.2.2.1 Terminology Bindings

PathDefinitionTypeReference
EligibilityRequest.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
EligibilityRequest.priority The timeliness with which processing is required: STAT, normal, DeferredExampleProcess Priority Codes
EligibilityRequest.benefitCategory Benefit categories such as: oral, medical, vision etc.ExampleBenefit Category Codes
EligibilityRequest.benefitSubCategory Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory Codes

13.2.3 Search Parameters

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

NameTypeDescriptionExpressionIn Common
createddateThe creation date for the EOBEligibilityRequest.created
entererreferenceThe party who is responsible for the requestEligibilityRequest.enterer
(Practitioner)
facilityreferenceFacility responsible for the goods and servicesEligibilityRequest.facility
(Location)
identifiertokenThe business identifier of the EligibilityEligibilityRequest.identifier
organizationreferenceThe reference to the providing organizationEligibilityRequest.organization
(Organization)
patientreferenceThe reference to the patientEligibilityRequest.patient
(Patient)
providerreferenceThe reference to the providerEligibilityRequest.provider
(Practitioner)