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

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

An Extension

R4: CoverageEligibilityResponse.purpose (new:code)

Element CoverageEligibilityResponse.purpose has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.purpose has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.patient (new:Reference(Patient))

Element CoverageEligibilityResponse.patient has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.patient has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.serviced[x] (new:date, Period)

Element CoverageEligibilityResponse.serviced[x] has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.serviced[x] has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.requestor

Element CoverageEligibilityResponse.requestor is mapped to FHIR STU3 element EligibilityResponse.requestProvider as SourceIsBroaderThanTarget. Element CoverageEligibilityResponse.requestor is mapped to FHIR STU3 element EligibilityResponse.requestOrganization as SourceIsBroaderThanTarget. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element CoverageEligibilityResponse.requestor with unmapped reference targets: PractitionerRole. Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

R4: CoverageEligibilityResponse.preAuthRef (new:string)

Element CoverageEligibilityResponse.preAuthRef has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.preAuthRef has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the response as not currently valid.

A code specifying the state of the resource instance.

R4: CoverageEligibilityResponse.purpose (new:code)

Element CoverageEligibilityResponse.purpose has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.purpose has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.patient (new:Reference(Patient))

Element CoverageEligibilityResponse.patient has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.patient has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.serviced[x] (new:date, Period)

Element CoverageEligibilityResponse.serviced[x] has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.serviced[x] has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.requestor

Element CoverageEligibilityResponse.requestor is mapped to FHIR STU3 element EligibilityResponse.requestProvider as SourceIsBroaderThanTarget. Element CoverageEligibilityResponse.requestor is mapped to FHIR STU3 element EligibilityResponse.requestOrganization as SourceIsBroaderThanTarget. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element CoverageEligibilityResponse.requestor with unmapped reference targets: PractitionerRole. Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

R4: CoverageEligibilityResponse.preAuthRef (new:string)

Element CoverageEligibilityResponse.preAuthRef has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.preAuthRef has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.outcome

Element CoverageEligibilityResponse.outcome is mapped to FHIR STU3 element EligibilityResponse.outcome as RelatedTo. The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

R4: CoverageEligibilityResponse.insurance.benefitPeriod (new:Period)

Element CoverageEligibilityResponse.insurance.benefitPeriod has a context of EligibilityResponse.insurance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.benefitPeriod has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.insurance.item.modifier (new:CodeableConcept)

Element CoverageEligibilityResponse.insurance.item.modifier has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.modifier has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). 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.

R4: CoverageEligibilityResponse.insurance.item.provider (new:Reference(Practitioner,PractitionerRole))

Element CoverageEligibilityResponse.insurance.item.provider has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.provider has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.insurance.item.authorizationRequired (new:boolean)

Element CoverageEligibilityResponse.insurance.item.authorizationRequired has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.authorizationRequired has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.insurance.item.authorizationSupporting (new:CodeableConcept)

Element CoverageEligibilityResponse.insurance.item.authorizationSupporting has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.authorizationSupporting has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.insurance.item.authorizationUrl (new:uri)

Element CoverageEligibilityResponse.insurance.item.authorizationUrl has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.authorizationUrl has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.insurance.item.benefit.used[x] additional types (string)

Element CoverageEligibilityResponse.insurance.item.benefit.used[x] is mapped to FHIR STU3 element EligibilityResponse.insurance.benefitBalance.financial.used[x] as SourceIsBroaderThanTarget. The mappings for CoverageEligibilityResponse.insurance.item.benefit.used[x] do not cover the following types: string. The target context EligibilityResponse.insurance.benefitBalance.financial.used[x] is a choice-type element and cannot directly hold extensions. The context is moved up to parent element EligibilityResponse.insurance.benefitBalance.financial.

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

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

An Extension

R4: CoverageEligibilityResponse.purpose (new:code)

Element CoverageEligibilityResponse.purpose has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.purpose has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.patient (new:Reference(Patient))

Element CoverageEligibilityResponse.patient has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.patient has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.serviced[x] (new:date, Period)

Element CoverageEligibilityResponse.serviced[x] has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.serviced[x] has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.requestor

Element CoverageEligibilityResponse.requestor is mapped to FHIR STU3 element EligibilityResponse.requestProvider as SourceIsBroaderThanTarget. Element CoverageEligibilityResponse.requestor is mapped to FHIR STU3 element EligibilityResponse.requestOrganization as SourceIsBroaderThanTarget. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element CoverageEligibilityResponse.requestor with unmapped reference targets: PractitionerRole. Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

R4: CoverageEligibilityResponse.preAuthRef (new:string)

Element CoverageEligibilityResponse.preAuthRef has a context of EligibilityResponse based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.preAuthRef has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The Response business identifier.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the response as not currently valid.

A code specifying the state of the resource instance.

The date when the enclosed suite of services were performed or completed.

The practitioner who is responsible for the services rendered to the patient.

The organization which is responsible for the services rendered to the patient.

Original request resource reference.

Transaction status: error, complete.

The codes SHALL be taken from Claim Processing Codes
(required to http://hl7.org/fhir/ValueSet/remittance-outcome|3.0.2)

The outcome of the processing.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: CoverageEligibilityResponse.outcome

Element CoverageEligibilityResponse.outcome is mapped to FHIR STU3 element EligibilityResponse.outcome as RelatedTo. The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Very often the text is the same as a displayName of one of the codings.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

A description of the status of the adjudication.

The Insurer who produced this adjudicated response.

Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.

The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: CoverageEligibilityResponse.insurance.benefitPeriod (new:Period)

Element CoverageEligibilityResponse.insurance.benefitPeriod has a context of EligibilityResponse.insurance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.benefitPeriod has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A suite of updated or additional Coverages from the Insurer.

The contract resource which may provide more detailed information.

Benefits and optionally current balances by Category.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: CoverageEligibilityResponse.insurance.item.modifier (new:CodeableConcept)

Element CoverageEligibilityResponse.insurance.item.modifier has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.modifier has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). 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.

R4: CoverageEligibilityResponse.insurance.item.provider (new:Reference(Practitioner,PractitionerRole))

Element CoverageEligibilityResponse.insurance.item.provider has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.provider has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.insurance.item.authorizationRequired (new:boolean)

Element CoverageEligibilityResponse.insurance.item.authorizationRequired has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.authorizationRequired has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.insurance.item.authorizationSupporting (new:CodeableConcept)

Element CoverageEligibilityResponse.insurance.item.authorizationSupporting has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.authorizationSupporting has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: CoverageEligibilityResponse.insurance.item.authorizationUrl (new:uri)

Element CoverageEligibilityResponse.insurance.item.authorizationUrl has a context of EligibilityResponse.insurance.benefitBalance based on following the parent source element upwards and mapping to EligibilityResponse. Element CoverageEligibilityResponse.insurance.item.authorizationUrl has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Dental, Vision, Medical, Pharmacy, Rehab etc.

Benefit categories such as: oral, medical, vision etc.

Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.

Benefit subcategories such as: oral-basic, major, glasses

True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.

A short name or tag for the benefit, for example MED01, or DENT2.

A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.

Network designation.

Code to classify in or out of network services

Unit designation: individual or family.

Unit covered/serviced - individual or family

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.

Coverage unit - annual, lifetime

Benefits Used to date.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: CoverageEligibilityResponse.insurance.item.benefit.used[x] additional types (string)

Element CoverageEligibilityResponse.insurance.item.benefit.used[x] is mapped to FHIR STU3 element EligibilityResponse.insurance.benefitBalance.financial.used[x] as SourceIsBroaderThanTarget. The mappings for CoverageEligibilityResponse.insurance.item.benefit.used[x] do not cover the following types: string. The target context EligibilityResponse.insurance.benefitBalance.financial.used[x] is a choice-type element and cannot directly hold extensions. The context is moved up to parent element EligibilityResponse.insurance.benefitBalance.financial.

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Deductable, visits, benefit amount.

Deductable, visits, co-pay, etc.

Benefits allowed.

Benefits used.

The form to be used for printing the content.

The forms codes.

Mutually exclusive with Services Provided (Item).

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

An error code,from a specified code system, which details why the eligibility check could not be performed.

The error codes for adjudication processing.