R4 Draft for Comment
FinancialThis page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R3 R2
| Financial Management Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Practitioner |
StructureDefinition for eligibilityresponse
{
"resourceType": "StructureDefinition",
"id": "EligibilityResponse",
"meta": {
"lastUpdated": "2017-12-20T15:52:34.818+11:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
}
],
"url": "http://hl7.org/fhir/StructureDefinition/EligibilityResponse",
"name": "EligibilityResponse",
"status": "draft",
"date": "2017-12-20T15:52:34+11:00",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"description": "This resource provides eligibility and plan details from the processing of an Eligibility resource.",
"fhirVersion": "3.2.0",
"mapping": [
{
"identity": "workflow",
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "cdanetv4",
"uri": "http://www.cda-adc.ca/en/services/cdanet/",
"name": "Canadian Dental Association eclaims standard"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "resource",
"abstract": false,
"type": "EligibilityResponse",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "EligibilityResponse",
"path": "EligibilityResponse",
"short": "EligibilityResponse resource",
"definition": "This resource provides eligibility and plan details from the processing of an Eligibility resource.",
"min": 0,
"max": "*",
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource"
},
{
"key": "dom-3",
"severity": "error",
"human": "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",
"expression": "contained.all(('#'+id in %resource.descendants().reference) or descendants().where(reference = '#').exists())",
"xpath": "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::reference[@value='#'])]))",
"source": "DomainResource"
}
],
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "w5",
"map": "financial.support"
}
]
},
{
"id": "EligibilityResponse.id",
"path": "EligibilityResponse.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"id": "EligibilityResponse.meta",
"path": "EligibilityResponse.meta",
"short": "Metadata about the resource",
"definition": "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.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"id": "EligibilityResponse.implicitRules",
"path": "EligibilityResponse.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comment": "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. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"id": "EligibilityResponse.language",
"path": "EligibilityResponse.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comment": "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).",
"min": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "EligibilityResponse.text",
"path": "EligibilityResponse.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "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.",
"comment": "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.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "EligibilityResponse.contained",
"path": "EligibilityResponse.contained",
"short": "Contained, inline Resources",
"definition": "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.",
"comment": "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.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityResponse.extension",
"path": "EligibilityResponse.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityResponse.modifierExtension",
"path": "EligibilityResponse.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityResponse.identifier",
"path": "EligibilityResponse.identifier",
"short": "Business Identifier",
"definition": "The Response business identifier.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "EligibilityResponse.status",
"path": "EligibilityResponse.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"comment": "This element is labeled as a modifier because the status contains codes that mark the response as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "EligibilityResponseStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "EligibilityResponse.created",
"path": "EligibilityResponse.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.recorded"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "EligibilityResponse.requestProvider",
"path": "EligibilityResponse.requestProvider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "cdanetv4",
"map": "B01"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "EligibilityResponse.requestOrganization",
"path": "EligibilityResponse.requestOrganization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer"
},
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "EligibilityResponse.request",
"path": "EligibilityResponse.request",
"short": "Eligibility reference",
"definition": "Original request resource reference.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/EligibilityRequest"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.basedOn"
},
{
"identity": "w5",
"map": "FiveWs.why[x]"
},
{
"identity": "cdanetv4",
"map": "A02|G01"
},
{
"identity": "w5",
"map": "why"
}
]
},
{
"id": "EligibilityResponse.outcome",
"path": "EligibilityResponse.outcome",
"short": "complete | error | partial",
"definition": "Transaction status: error, complete.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "required",
"description": "The outcome of the processing.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
}
},
{
"id": "EligibilityResponse.disposition",
"path": "EligibilityResponse.disposition",
"short": "Disposition Message",
"definition": "A description of the status of the adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.note"
}
]
},
{
"id": "EligibilityResponse.insurer",
"path": "EligibilityResponse.insurer",
"short": "Insurer issuing the coverage",
"definition": "The Insurer who produced this adjudicated response.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
]
},
{
"id": "EligibilityResponse.inforce",
"path": "EligibilityResponse.inforce",
"short": "Coverage inforce indicator",
"definition": "Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "EligibilityResponse.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "EligibilityResponse.insurance",
"short": "Details by insurance coverage",
"definition": "The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "EligibilityResponse.insurance.id",
"path": "EligibilityResponse.insurance.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.insurance.extension",
"path": "EligibilityResponse.insurance.extension",
"short": "Additional Content defined by implementations",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.insurance.modifierExtension",
"path": "EligibilityResponse.insurance.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityResponse.insurance.coverage",
"path": "EligibilityResponse.insurance.coverage",
"short": "Updated Coverage details",
"definition": "A suite of updated or additional Coverages from the Insurer.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
]
},
{
"id": "EligibilityResponse.insurance.contract",
"path": "EligibilityResponse.insurance.contract",
"short": "Contract details",
"definition": "The contract resource which may provide more detailed information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Contract"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefits"
}
],
"path": "EligibilityResponse.insurance.benefitBalance",
"short": "Benefits by Category",
"definition": "Benefits and optionally current balances by Category.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.id",
"path": "EligibilityResponse.insurance.benefitBalance.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.extension",
"path": "EligibilityResponse.insurance.benefitBalance.extension",
"short": "Additional Content defined by implementations",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.modifierExtension",
"path": "EligibilityResponse.insurance.benefitBalance.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.category",
"path": "EligibilityResponse.insurance.benefitBalance.category",
"short": "Type of services covered",
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
}
],
"strength": "example",
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-category"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.subCategory",
"path": "EligibilityResponse.insurance.benefitBalance.subCategory",
"short": "Detailed services covered within the type",
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.excluded",
"path": "EligibilityResponse.insurance.benefitBalance.excluded",
"short": "Excluded from the plan",
"definition": "True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.name",
"path": "EligibilityResponse.insurance.benefitBalance.name",
"short": "Short name for the benefit",
"definition": "A short name or tag for the benefit, for example MED01, or DENT2.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.description",
"path": "EligibilityResponse.insurance.benefitBalance.description",
"short": "Description of the benefit or services covered",
"definition": "A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.network",
"path": "EligibilityResponse.insurance.benefitBalance.network",
"short": "In or out of network",
"definition": "Network designation.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitNetwork"
}
],
"strength": "example",
"description": "Code to classify in or out of network services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-network"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.unit",
"path": "EligibilityResponse.insurance.benefitBalance.unit",
"short": "Individual or family",
"definition": "Unit designation: individual or family.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitUnit"
}
],
"strength": "example",
"description": "Unit covered/serviced - individual or family",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-unit"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.term",
"path": "EligibilityResponse.insurance.benefitBalance.term",
"short": "Annual or lifetime",
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitTerm"
}
],
"strength": "example",
"description": "Coverage unit - annual, lifetime",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-term"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
}
],
"path": "EligibilityResponse.insurance.benefitBalance.financial",
"short": "Benefit Summary",
"definition": "Benefits Used to date.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.id",
"path": "EligibilityResponse.insurance.benefitBalance.financial.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.extension",
"path": "EligibilityResponse.insurance.benefitBalance.financial.extension",
"short": "Additional Content defined by implementations",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.modifierExtension",
"path": "EligibilityResponse.insurance.benefitBalance.financial.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.type",
"path": "EligibilityResponse.insurance.benefitBalance.financial.type",
"short": "Deductable, visits, benefit amount",
"definition": "Deductable, visits, benefit amount.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitType"
}
],
"strength": "example",
"description": "Deductable, visits, co-pay, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-type"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.allowed[x]",
"path": "EligibilityResponse.insurance.benefitBalance.financial.allowed[x]",
"short": "Benefits allowed",
"definition": "Benefits allowed.",
"min": 0,
"max": "1",
"type": [
{
"code": "unsignedInt"
},
{
"code": "string"
},
{
"code": "Money"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.used[x]",
"path": "EligibilityResponse.insurance.benefitBalance.financial.used[x]",
"short": "Benefits used",
"definition": "Benefits used.",
"min": 0,
"max": "1",
"type": [
{
"code": "unsignedInt"
},
{
"code": "Money"
}
]
},
{
"id": "EligibilityResponse.preAuthRef",
"path": "EligibilityResponse.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A reference from the Insurer to which these services pertain.",
"requirements": "To provide any pre-determination or prior authorization reference.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "23"
}
]
},
{
"id": "EligibilityResponse.authorization",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Authorization"
}
],
"path": "EligibilityResponse.authorization",
"short": "Services which may require prior authorization",
"definition": "A list of billable services for which an authorization prior to service delivery may be required by the payor.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "EligibilityResponse.authorization.id",
"path": "EligibilityResponse.authorization.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.authorization.extension",
"path": "EligibilityResponse.authorization.extension",
"short": "Additional Content defined by implementations",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.authorization.modifierExtension",
"path": "EligibilityResponse.authorization.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityResponse.authorization.authorizationSequence",
"path": "EligibilityResponse.authorization.authorizationSequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "EligibilityResponse.authorization.required",
"path": "EligibilityResponse.authorization.required",
"short": "Authorization required flag",
"definition": "A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service delivery.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "EligibilityResponse.authorization.note",
"path": "EligibilityResponse.authorization.note",
"short": "Comments and instructions",
"definition": "Any comments regarding information or actions assciated with the pre-authorization.",
"min": 0,
"max": "*",
"type": [
{
"code": "Annotation"
}
]
},
{
"id": "EligibilityResponse.form",
"path": "EligibilityResponse.form",
"short": "Printed Form Identifier",
"definition": "The form to be used for printing the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
},
"mapping": [
{
"identity": "cdanetv4",
"map": "G42"
}
]
},
{
"id": "EligibilityResponse.error",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Errors"
}
],
"path": "EligibilityResponse.error",
"short": "Processing errors",
"definition": "Mutually exclusive with Services Provided (Item).",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "EligibilityResponse.error.id",
"path": "EligibilityResponse.error.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.error.extension",
"path": "EligibilityResponse.error.extension",
"short": "Additional Content defined by implementations",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "EligibilityResponse.error.modifierExtension",
"path": "EligibilityResponse.error.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "EligibilityResponse.error.code",
"path": "EligibilityResponse.error.code",
"short": "Error code detailing processing issues",
"definition": "An error code,from a specified code system, which details why the eligibility check could not be performed.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationError"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "The error codes for adjudication processing.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-error"
}
}
}
]
},
"differential": {
"element": [
{
"id": "EligibilityResponse",
"path": "EligibilityResponse",
"short": "EligibilityResponse resource",
"definition": "This resource provides eligibility and plan details from the processing of an Eligibility resource.",
"min": 0,
"max": "*",
"mapping": [
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "w5",
"map": "financial.support"
}
]
},
{
"id": "EligibilityResponse.identifier",
"path": "EligibilityResponse.identifier",
"short": "Business Identifier",
"definition": "The Response business identifier.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "EligibilityResponse.status",
"path": "EligibilityResponse.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"comment": "This element is labeled as a modifier because the status contains codes that mark the response as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "EligibilityResponseStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "EligibilityResponse.created",
"path": "EligibilityResponse.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.recorded"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "EligibilityResponse.requestProvider",
"path": "EligibilityResponse.requestProvider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "cdanetv4",
"map": "B01"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "EligibilityResponse.requestOrganization",
"path": "EligibilityResponse.requestOrganization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer"
},
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "EligibilityResponse.request",
"path": "EligibilityResponse.request",
"short": "Eligibility reference",
"definition": "Original request resource reference.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/EligibilityRequest"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.basedOn"
},
{
"identity": "w5",
"map": "FiveWs.why[x]"
},
{
"identity": "cdanetv4",
"map": "A02|G01"
},
{
"identity": "w5",
"map": "why"
}
]
},
{
"id": "EligibilityResponse.outcome",
"path": "EligibilityResponse.outcome",
"short": "complete | error | partial",
"definition": "Transaction status: error, complete.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "required",
"description": "The outcome of the processing.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
}
},
{
"id": "EligibilityResponse.disposition",
"path": "EligibilityResponse.disposition",
"short": "Disposition Message",
"definition": "A description of the status of the adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.note"
}
]
},
{
"id": "EligibilityResponse.insurer",
"path": "EligibilityResponse.insurer",
"short": "Insurer issuing the coverage",
"definition": "The Insurer who produced this adjudicated response.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
]
},
{
"id": "EligibilityResponse.inforce",
"path": "EligibilityResponse.inforce",
"short": "Coverage inforce indicator",
"definition": "Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "EligibilityResponse.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "EligibilityResponse.insurance",
"short": "Details by insurance coverage",
"definition": "The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "EligibilityResponse.insurance.coverage",
"path": "EligibilityResponse.insurance.coverage",
"short": "Updated Coverage details",
"definition": "A suite of updated or additional Coverages from the Insurer.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
]
},
{
"id": "EligibilityResponse.insurance.contract",
"path": "EligibilityResponse.insurance.contract",
"short": "Contract details",
"definition": "The contract resource which may provide more detailed information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Contract"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefits"
}
],
"path": "EligibilityResponse.insurance.benefitBalance",
"short": "Benefits by Category",
"definition": "Benefits and optionally current balances by Category.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.category",
"path": "EligibilityResponse.insurance.benefitBalance.category",
"short": "Type of services covered",
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
}
],
"strength": "example",
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-category"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.subCategory",
"path": "EligibilityResponse.insurance.benefitBalance.subCategory",
"short": "Detailed services covered within the type",
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.excluded",
"path": "EligibilityResponse.insurance.benefitBalance.excluded",
"short": "Excluded from the plan",
"definition": "True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.name",
"path": "EligibilityResponse.insurance.benefitBalance.name",
"short": "Short name for the benefit",
"definition": "A short name or tag for the benefit, for example MED01, or DENT2.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.description",
"path": "EligibilityResponse.insurance.benefitBalance.description",
"short": "Description of the benefit or services covered",
"definition": "A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.network",
"path": "EligibilityResponse.insurance.benefitBalance.network",
"short": "In or out of network",
"definition": "Network designation.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitNetwork"
}
],
"strength": "example",
"description": "Code to classify in or out of network services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-network"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.unit",
"path": "EligibilityResponse.insurance.benefitBalance.unit",
"short": "Individual or family",
"definition": "Unit designation: individual or family.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitUnit"
}
],
"strength": "example",
"description": "Unit covered/serviced - individual or family",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-unit"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.term",
"path": "EligibilityResponse.insurance.benefitBalance.term",
"short": "Annual or lifetime",
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitTerm"
}
],
"strength": "example",
"description": "Coverage unit - annual, lifetime",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-term"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
}
],
"path": "EligibilityResponse.insurance.benefitBalance.financial",
"short": "Benefit Summary",
"definition": "Benefits Used to date.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.type",
"path": "EligibilityResponse.insurance.benefitBalance.financial.type",
"short": "Deductable, visits, benefit amount",
"definition": "Deductable, visits, benefit amount.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitType"
}
],
"strength": "example",
"description": "Deductable, visits, co-pay, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-type"
}
}
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.allowed[x]",
"path": "EligibilityResponse.insurance.benefitBalance.financial.allowed[x]",
"short": "Benefits allowed",
"definition": "Benefits allowed.",
"min": 0,
"max": "1",
"type": [
{
"code": "unsignedInt"
},
{
"code": "string"
},
{
"code": "Money"
}
]
},
{
"id": "EligibilityResponse.insurance.benefitBalance.financial.used[x]",
"path": "EligibilityResponse.insurance.benefitBalance.financial.used[x]",
"short": "Benefits used",
"definition": "Benefits used.",
"min": 0,
"max": "1",
"type": [
{
"code": "unsignedInt"
},
{
"code": "Money"
}
]
},
{
"id": "EligibilityResponse.preAuthRef",
"path": "EligibilityResponse.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A reference from the Insurer to which these services pertain.",
"requirements": "To provide any pre-determination or prior authorization reference.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "23"
}
]
},
{
"id": "EligibilityResponse.authorization",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Authorization"
}
],
"path": "EligibilityResponse.authorization",
"short": "Services which may require prior authorization",
"definition": "A list of billable services for which an authorization prior to service delivery may be required by the payor.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "EligibilityResponse.authorization.authorizationSequence",
"path": "EligibilityResponse.authorization.authorizationSequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "EligibilityResponse.authorization.required",
"path": "EligibilityResponse.authorization.required",
"short": "Authorization required flag",
"definition": "A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service delivery.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "EligibilityResponse.authorization.note",
"path": "EligibilityResponse.authorization.note",
"short": "Comments and instructions",
"definition": "Any comments regarding information or actions assciated with the pre-authorization.",
"min": 0,
"max": "*",
"type": [
{
"code": "Annotation"
}
]
},
{
"id": "EligibilityResponse.form",
"path": "EligibilityResponse.form",
"short": "Printed Form Identifier",
"definition": "The form to be used for printing the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
},
"mapping": [
{
"identity": "cdanetv4",
"map": "G42"
}
]
},
{
"id": "EligibilityResponse.error",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Errors"
}
],
"path": "EligibilityResponse.error",
"short": "Processing errors",
"definition": "Mutually exclusive with Services Provided (Item).",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "EligibilityResponse.error.code",
"path": "EligibilityResponse.error.code",
"short": "Error code detailing processing issues",
"definition": "An error code,from a specified code system, which details why the eligibility check could not be performed.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationError"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "The error codes for adjudication processing.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-error"
}
}
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
®© HL7.org 2011+. FHIR Release 4 Draft for Comment (Jan-2018 v3.2.0-12885) generated on Wed, Dec 20, 2017 15:57+1100. QA Page
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