Generated Narrative: StructureDefinition profile-CoverageEligibilityResponse-for-EligibilityResponse Name Flags Card. Type Description & Constraints EligibilityResponse 0..* EligibilityResponse EligibilityResponse resource #xD; Slices for extension 2..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:purpose 1..* code R4: auth-requirements | benefits | discovery | validation (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.purpose Binding: R4EligibilityresponsePurposeForR3 (0.1.0) (required): A code specifying the types of information being requested. #xD; extension:patient 1..1 Reference(Cross-version Profile for R4.Patient for use in FHIR STU3(0.1.0) | Patient) R4: Intended recipient of products and services (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.patient #xD; extension:serviced 0..1 date, Period R4: Estimated date or dates of service (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.serviced #xD; extension:requestor 0..1 ?gen-e1? [CanonicalType[http://hl7.org/fhir/StructureDefinition/alternate-reference]] R4: Party responsible for the request URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; extension:preAuthRef 0..1 string R4: Preauthorization reference (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.preAuthRef #xD; outcome #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:outcome 1..1 code R4: queued | complete | error | partial URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.outcome Binding: R4RemittanceOutcomeForR3 (0.1.0) (required): The outcome of the processing. #xD; insurance #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:benefitPeriod 0..1 Period R4: When the benefits are applicable (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.insurance.benefitPeriod #xD; benefitBalance #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:modifier 0..* CodeableConcept R4: Product or service billing modifiers (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.insurance.item.modifier Binding: Modifier type Codes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. #xD; extension:provider 0..1 Reference(Cross-version Profile for R4.Practitioner for use in FHIR STU3(0.1.0) | Practitioner | Cross-version Profile for R4.PractitionerRole for use in FHIR STU3(0.1.0) | PractitionerRole) R4: Performing practitioner (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.insurance.item.provider #xD; extension:authorizationRequired 0..1 boolean R4: Authorization required flag (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.insurance.item.authorizationRequired #xD; extension:authorizationSupporting 0..* CodeableConcept R4: Type of required supporting materials (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.insurance.item.authorizationSupporting Binding: R4CoverageeligibilityresponseExAuthSupportForR3 (0.1.0) (example): Type of supporting information to provide with a preauthorization. #xD; extension:authorizationUrl 0..1 uri R4: Preauthorization requirements endpoint (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.insurance.item.authorizationUrl #xD; financial #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:used 0..1 string R4: used additional types URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-CoverageEligibilityResponse.insurance.item.benefit.used #xD; Documentation for this format
Cross-version Profile for R4.CoverageEligibilityResponse for use in FHIR STU3
This cross-version profile allows R4 CoverageEligibilityResponse content to be represented via FHIR STU3 EligibilityResponse resources.
Canadian Dental Association eclaims standard
This resource provides eligibility and plan details from the processing of an Eligibility resource.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL NOT contain any narrative
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
contained.where(('#'+id in %resource.descendants().reference).not()).empty()
not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))
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 set of rules under which this content was created
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).
Text summary of the resource, for human interpretation
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.
R4: auth-requirements | benefits | discovery | validation (new)
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).
All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
R4: Intended recipient of products and services (new)
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: Estimated date or dates of service (new)
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.
active | cancelled | draft | entered-in-error
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.
unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
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.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Plain text representation of the concept
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.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
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.
R4: When the benefits are applicable (new)
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.
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.
R4: Product or service billing modifiers (new)
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: Type of required supporting materials (new)
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: Preauthorization requirements endpoint (new)
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).
Dental, Vision, Medical, Pharmacy, Rehab etc.
Benefit categories such as: oral, medical, vision etc.
Detailed services covered within the type
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.
Description of the benefit or services covered
A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.
Code to classify in or out of network services
Unit covered/serviced - individual or family
The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.
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`.
The form to be used for printing the content.
Mutually exclusive with Services Provided (Item).
Additional Content defined by implementations
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.
An error code,from a specified code system, which details why the eligibility check could not be performed.
The error codes for adjudication processing.