Extensions for Using Data Elements from FHIR R5 in FHIR R4
0.1.0 - STU International flag

Extensions for Using Data Elements from FHIR R5 in FHIR R4 - Downloaded Version null See the Directory of published versions

Resource Profile: Profile_R5_CoverageEligibilityResponse_R4

Official URL: http://hl7.org/fhir/5.0/StructureDefinition/profile-CoverageEligibilityResponse Version: 0.1.0
Standards status: Trial-use Maturity Level: 0 Computable Name: Profile_R5_CoverageEligibilityResponse_R4

This cross-version profile allows R5 CoverageEligibilityResponse content to be represented via FHIR R4 CoverageEligibilityResponse resources.

Usages:

  • This Profile is not used by any profiles in this Implementation Guide

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse(4.0.1) CoverageEligibilityResponse resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
.... extension:event 0..* (Complex) R5: Event information (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.event
Constraints: ext-1
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
Constraints: ext-1
... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... created Σ 1..1 dateTime Response creation date
... request Σ 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.
... insurer Σ 1..1 Reference(Organization) Coverage issuer

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error CoverageEligibilityResponse 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()
dom-5 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice CoverageEligibilityResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error CoverageEligibilityResponse.implicitRules, CoverageEligibilityResponse.extension, CoverageEligibilityResponse.extension:event, CoverageEligibilityResponse.modifierExtension, CoverageEligibilityResponse.status, CoverageEligibilityResponse.purpose, CoverageEligibilityResponse.patient, CoverageEligibilityResponse.created, CoverageEligibilityResponse.request, CoverageEligibilityResponse.outcome, CoverageEligibilityResponse.insurer All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error CoverageEligibilityResponse.extension, CoverageEligibilityResponse.extension:event, CoverageEligibilityResponse.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from CoverageEligibilityResponse

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse(4.0.1) CoverageEligibilityResponse resource
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:event 0..* (Complex) R5: Event information (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.event
... error
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:expression 0..* string R5: FHIRPath of element(s) related to issue (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.error.expression

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse(4.0.1) CoverageEligibilityResponse resource
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
.... extension:event 0..* (Complex) R5: Event information (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.event
Constraints: ext-1
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
Constraints: ext-1
... identifier 0..* Identifier Business Identifier for coverage eligiblity request
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... serviced[x] 0..1 Estimated date or dates of service
.... servicedDate date
.... servicedPeriod Period
... created Σ 1..1 dateTime Response creation date
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request Σ 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.
... disposition 0..1 string Disposition Message
... insurer Σ 1..1 Reference(Organization) Coverage issuer
... insurance 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... inforce 0..1 boolean Coverage inforce indicator
.... benefitPeriod 0..1 Period When the benefits are applicable
.... item C 0..* BackboneElement Benefits and authorization details
Constraints: ces-1
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (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.
..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Excluded from the plan
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
..... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
..... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
..... benefit 0..* BackboneElement Benefit Summary
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
...... allowed[x] 0..1 Benefits allowed
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
...... used[x] 0..1 Benefits used
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... extension:expression 0..* string R5: FHIRPath of element(s) related to issue (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.error.expression
Constraints: ext-1
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​language Base preferred Common Languages . 📍4.0.1 tx.fhir.org
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.network Base example Network Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.authorizationSupporting Base example CoverageEligibilityResponse Auth Support Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​form Base example Forms 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​error.code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
ces-1 error CoverageEligibilityResponse.insurance.item SHALL contain a category or a billcode but not both. category.exists() xor productOrService.exists()
dom-2 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error CoverageEligibilityResponse 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()
dom-5 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice CoverageEligibilityResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error CoverageEligibilityResponse.meta, CoverageEligibilityResponse.implicitRules, CoverageEligibilityResponse.language, CoverageEligibilityResponse.text, CoverageEligibilityResponse.extension, CoverageEligibilityResponse.extension:event, CoverageEligibilityResponse.modifierExtension, CoverageEligibilityResponse.identifier, CoverageEligibilityResponse.status, CoverageEligibilityResponse.purpose, CoverageEligibilityResponse.patient, CoverageEligibilityResponse.serviced[x], CoverageEligibilityResponse.created, CoverageEligibilityResponse.requestor, CoverageEligibilityResponse.request, CoverageEligibilityResponse.outcome, CoverageEligibilityResponse.disposition, CoverageEligibilityResponse.insurer, CoverageEligibilityResponse.insurance, CoverageEligibilityResponse.insurance.extension, CoverageEligibilityResponse.insurance.modifierExtension, CoverageEligibilityResponse.insurance.coverage, CoverageEligibilityResponse.insurance.inforce, CoverageEligibilityResponse.insurance.benefitPeriod, CoverageEligibilityResponse.insurance.item, CoverageEligibilityResponse.insurance.item.extension, CoverageEligibilityResponse.insurance.item.modifierExtension, CoverageEligibilityResponse.insurance.item.category, CoverageEligibilityResponse.insurance.item.productOrService, CoverageEligibilityResponse.insurance.item.modifier, CoverageEligibilityResponse.insurance.item.provider, CoverageEligibilityResponse.insurance.item.excluded, CoverageEligibilityResponse.insurance.item.name, CoverageEligibilityResponse.insurance.item.description, CoverageEligibilityResponse.insurance.item.network, CoverageEligibilityResponse.insurance.item.unit, CoverageEligibilityResponse.insurance.item.term, CoverageEligibilityResponse.insurance.item.benefit, CoverageEligibilityResponse.insurance.item.benefit.extension, CoverageEligibilityResponse.insurance.item.benefit.modifierExtension, CoverageEligibilityResponse.insurance.item.benefit.type, CoverageEligibilityResponse.insurance.item.benefit.allowed[x], CoverageEligibilityResponse.insurance.item.benefit.used[x], CoverageEligibilityResponse.insurance.item.authorizationRequired, CoverageEligibilityResponse.insurance.item.authorizationSupporting, CoverageEligibilityResponse.insurance.item.authorizationUrl, CoverageEligibilityResponse.preAuthRef, CoverageEligibilityResponse.form, CoverageEligibilityResponse.error, CoverageEligibilityResponse.error.extension, CoverageEligibilityResponse.error.extension:expression, CoverageEligibilityResponse.error.modifierExtension, CoverageEligibilityResponse.error.code All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error CoverageEligibilityResponse.extension, CoverageEligibilityResponse.extension:event, CoverageEligibilityResponse.modifierExtension, CoverageEligibilityResponse.insurance.extension, CoverageEligibilityResponse.insurance.modifierExtension, CoverageEligibilityResponse.insurance.item.extension, CoverageEligibilityResponse.insurance.item.modifierExtension, CoverageEligibilityResponse.insurance.item.benefit.extension, CoverageEligibilityResponse.insurance.item.benefit.modifierExtension, CoverageEligibilityResponse.error.extension, CoverageEligibilityResponse.error.extension:expression, CoverageEligibilityResponse.error.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse(4.0.1) CoverageEligibilityResponse resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
.... extension:event 0..* (Complex) R5: Event information (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.event
Constraints: ext-1
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
Constraints: ext-1
... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... created Σ 1..1 dateTime Response creation date
... request Σ 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.
... insurer Σ 1..1 Reference(Organization) Coverage issuer

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error CoverageEligibilityResponse 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()
dom-5 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice CoverageEligibilityResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error CoverageEligibilityResponse.implicitRules, CoverageEligibilityResponse.extension, CoverageEligibilityResponse.extension:event, CoverageEligibilityResponse.modifierExtension, CoverageEligibilityResponse.status, CoverageEligibilityResponse.purpose, CoverageEligibilityResponse.patient, CoverageEligibilityResponse.created, CoverageEligibilityResponse.request, CoverageEligibilityResponse.outcome, CoverageEligibilityResponse.insurer All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error CoverageEligibilityResponse.extension, CoverageEligibilityResponse.extension:event, CoverageEligibilityResponse.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from CoverageEligibilityResponse

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse(4.0.1) CoverageEligibilityResponse resource
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:event 0..* (Complex) R5: Event information (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.event
... error
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:expression 0..* string R5: FHIRPath of element(s) related to issue (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.error.expression

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse(4.0.1) CoverageEligibilityResponse resource
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
.... extension:event 0..* (Complex) R5: Event information (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.event
Constraints: ext-1
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
Constraints: ext-1
... identifier 0..* Identifier Business Identifier for coverage eligiblity request
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... serviced[x] 0..1 Estimated date or dates of service
.... servicedDate date
.... servicedPeriod Period
... created Σ 1..1 dateTime Response creation date
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request Σ 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.
... disposition 0..1 string Disposition Message
... insurer Σ 1..1 Reference(Organization) Coverage issuer
... insurance 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... inforce 0..1 boolean Coverage inforce indicator
.... benefitPeriod 0..1 Period When the benefits are applicable
.... item C 0..* BackboneElement Benefits and authorization details
Constraints: ces-1
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (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.
..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Excluded from the plan
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
..... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
..... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
..... benefit 0..* BackboneElement Benefit Summary
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Constraints: ext-1
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
...... allowed[x] 0..1 Benefits allowed
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
...... used[x] 0..1 Benefits used
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... extension:expression 0..* string R5: FHIRPath of element(s) related to issue (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.error.expression
Constraints: ext-1
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
Constraints: ext-1
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​language Base preferred Common Languages . 📍4.0.1 tx.fhir.org
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.network Base example Network Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.authorizationSupporting Base example CoverageEligibilityResponse Auth Support Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​form Base example Forms 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​error.code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
ces-1 error CoverageEligibilityResponse.insurance.item SHALL contain a category or a billcode but not both. category.exists() xor productOrService.exists()
dom-2 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error CoverageEligibilityResponse 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()
dom-5 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice CoverageEligibilityResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error CoverageEligibilityResponse.meta, CoverageEligibilityResponse.implicitRules, CoverageEligibilityResponse.language, CoverageEligibilityResponse.text, CoverageEligibilityResponse.extension, CoverageEligibilityResponse.extension:event, CoverageEligibilityResponse.modifierExtension, CoverageEligibilityResponse.identifier, CoverageEligibilityResponse.status, CoverageEligibilityResponse.purpose, CoverageEligibilityResponse.patient, CoverageEligibilityResponse.serviced[x], CoverageEligibilityResponse.created, CoverageEligibilityResponse.requestor, CoverageEligibilityResponse.request, CoverageEligibilityResponse.outcome, CoverageEligibilityResponse.disposition, CoverageEligibilityResponse.insurer, CoverageEligibilityResponse.insurance, CoverageEligibilityResponse.insurance.extension, CoverageEligibilityResponse.insurance.modifierExtension, CoverageEligibilityResponse.insurance.coverage, CoverageEligibilityResponse.insurance.inforce, CoverageEligibilityResponse.insurance.benefitPeriod, CoverageEligibilityResponse.insurance.item, CoverageEligibilityResponse.insurance.item.extension, CoverageEligibilityResponse.insurance.item.modifierExtension, CoverageEligibilityResponse.insurance.item.category, CoverageEligibilityResponse.insurance.item.productOrService, CoverageEligibilityResponse.insurance.item.modifier, CoverageEligibilityResponse.insurance.item.provider, CoverageEligibilityResponse.insurance.item.excluded, CoverageEligibilityResponse.insurance.item.name, CoverageEligibilityResponse.insurance.item.description, CoverageEligibilityResponse.insurance.item.network, CoverageEligibilityResponse.insurance.item.unit, CoverageEligibilityResponse.insurance.item.term, CoverageEligibilityResponse.insurance.item.benefit, CoverageEligibilityResponse.insurance.item.benefit.extension, CoverageEligibilityResponse.insurance.item.benefit.modifierExtension, CoverageEligibilityResponse.insurance.item.benefit.type, CoverageEligibilityResponse.insurance.item.benefit.allowed[x], CoverageEligibilityResponse.insurance.item.benefit.used[x], CoverageEligibilityResponse.insurance.item.authorizationRequired, CoverageEligibilityResponse.insurance.item.authorizationSupporting, CoverageEligibilityResponse.insurance.item.authorizationUrl, CoverageEligibilityResponse.preAuthRef, CoverageEligibilityResponse.form, CoverageEligibilityResponse.error, CoverageEligibilityResponse.error.extension, CoverageEligibilityResponse.error.extension:expression, CoverageEligibilityResponse.error.modifierExtension, CoverageEligibilityResponse.error.code All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error CoverageEligibilityResponse.extension, CoverageEligibilityResponse.extension:event, CoverageEligibilityResponse.modifierExtension, CoverageEligibilityResponse.insurance.extension, CoverageEligibilityResponse.insurance.modifierExtension, CoverageEligibilityResponse.insurance.item.extension, CoverageEligibilityResponse.insurance.item.modifierExtension, CoverageEligibilityResponse.insurance.item.benefit.extension, CoverageEligibilityResponse.insurance.item.benefit.modifierExtension, CoverageEligibilityResponse.error.extension, CoverageEligibilityResponse.error.extension:expression, CoverageEligibilityResponse.error.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

 

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