Generated Narrative: StructureDefinition profile-CoverageEligibilityResponse Name Flags Card. Type Description & Constraints CoverageEligibilityResponse 0..* CoverageEligibilityResponse(4.0.1) CoverageEligibilityResponse resource #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:event 0..* (Complex) R5: Event information (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-CoverageEligibilityResponse.event #xD; error #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; 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 #xD; Documentation for this format
Cross-version Profile for R5.CoverageEligibilityResponse for use in FHIR R4
This cross-version profile allows R5 CoverageEligibilityResponse content to be represented via FHIR R4 CoverageEligibilityResponse resources.
Canadian Dental Association eclaims standard
This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest 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 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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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 a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
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 might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled 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 can 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 information 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
R5: `CoverageEligibilityResponse.event` (new:BackboneElement)
Element `CoverageEligibilityResponse.event` has a context of CoverageEligibilityResponse based on following the parent source element upwards and mapping to `CoverageEligibilityResponse`. Element `CoverageEligibilityResponse.event` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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.
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Business Identifier for coverage eligiblity request
A unique identifier assigned to this coverage eligiblity request.
Allows coverage eligibility requests to be distinguished and referenced.
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
A code specifying the state of the resource instance.
auth-requirements | benefits | discovery | validation
Code to specify whether requesting: prior authorization requirements for some service categories or billing codes; benefits for coverages specified or discovered; discovery and return of coverages for the patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.
To indicate the processing actions requested.
A code specifying the types of information being requested.
Intended recipient of products and services
The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.
Required to provide context and coverage validation.
The date or dates when the enclosed suite of services were performed or completed.
Required to provide time context for the request.
Need to record a timestamp for use by both the recipient and the issuer.
The provider which is responsible for the request.
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.
Reference to the original request resource.
Needed to allow the response to be linked to the request.
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).
To advise the requestor of an overall processing outcome.
A human readable description of the status of the adjudication.
The Insurer who issued the coverage in question and is the author of the response.
Financial instruments for reimbursement for the health care products and services.
All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
There must be at least one coverage for which eligibility is requested.
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Extensions that cannot be ignored even if unrecognized
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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Required to allow the adjudicator to locate the correct policy and history within their information system.
Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.
Needed to convey the answer to the eligibility validation request.
The term of the benefits documented in this response.
Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.
Benefits and optionally current balances, and authorization details by category or service.
SHALL contain a category or a billcode but not both.
category.exists() xor productOrService.exists()
exists(f:category) or exists(f:productOrService)
Code to identify the general type of benefits under which products and services are provided.
Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Needed to convey the category of service or product for which eligibility is sought.
Benefit categories such as: oral, medical, vision etc.
This contains the product, service, drug or other billing code for the item.
Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).
Needed to convey the actual service or product for which eligibility is sought.
Item typification or modifiers codes to convey additional context for the product or service.
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.
To support provision of the item or to charge an elevated fee.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
The practitioner who is eligible for the provision of the product or service.
True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
Needed to identify items that are specifically excluded from the coverage.
Required to align with other plan names.
Description of the benefit or services covered
A richer description of the benefit or services covered.
For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
Needed as in or out of network providers are treated differently under the coverage.
Code to classify in or out of network services.
Indicates if the benefits apply to an individual or to the family.
Needed for the understanding of the benefits.
Unit covered/serviced - individual or family.
The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
Classification of benefit being provided.
For example: deductible, visits, benefit amount.
Needed to convey the nature of the benefit.
The quantity of the benefit which is permitted under the coverage.
Needed to convey the benefits offered under the coverage.
The quantity of the benefit which have been consumed to date.
Needed to convey the benefits consumed to date.
A boolean flag indicating whether a preauthorization is required prior to actual service delivery.
Needed to convey that preauthorization is required.
Codes or comments regarding information or actions associated with the preauthorization.
Needed to inform the provider of collateral materials or actions needed for preauthorization.
Type of supporting information to provide with a preauthorization.
A web location for obtaining requirements or descriptive information regarding the preauthorization.
Needed to enable insurers to advise providers of informative information.
A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.
To provide any preauthorization reference for provider use.
A code for the form to be used for printing the content.
May be needed to identify specific jurisdictional forms.
Needed to specify the specific form used for producing output for this response.
Errors encountered during the processing of the request.
Need to communicate processing issues to the requestor.
R5: FHIRPath of element(s) related to issue (new)
R5: `CoverageEligibilityResponse.error.expression` (new:string)
Element `CoverageEligibilityResponse.error.expression` has a context of CoverageEligibilityResponse.error based on following the parent source element upwards and mapping to `CoverageEligibilityResponse`. Element `CoverageEligibilityResponse.error.expression` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element). The root of the FHIRPath is the resource or bundle that generated OperationOutcome. Each FHIRPath SHALL resolve to a single node.
An error code,from a specified code system, which details why the eligibility check could not be performed.
The error codes for adjudication processing.