Current Build

13.2 Resource EligibilityRequest - Content

Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Patient, Practitioner

The EligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an EligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.

The EligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an Eligibility Response, with information regarding whether the stated coverage is valid and in-force, and potentially the amount of coverage which may be available to any services classes identified in this request.

For Balloters: The optional Authorization subclass has been added for comment ballot review. It is intended to convey the billable services which may be performed and for which the provider wishes to determine whether it needs to submit a prior authorization (pre-authorization) request. The EligibilityResponse would return a boolean flag indicating whether prior authorization is required and an optional text element would convey any special instructions.

This resource is referenced by eligibilityresponse

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityRequest TUDomainResourceDetermine insurance validity and scope of coverage
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible practitioner
... insurer 0..1Reference(Organization)Target
... facility 0..1Reference(Location)Servicing Facility
... coverage 0..1Reference(Coverage)Insurance or medical plan
... businessArrangement 0..1stringBusiness agreement
... benefitCategory 0..1CodeableConceptType of services covered
Benefit Category Codes (Example)
... benefitSubCategory 0..1CodeableConceptDetailed services covered within the type
Benefit SubCategory Codes (Example)
... authorization 0..*BackboneElementServices which may require prior authorization
.... sequence 1..1positiveIntProcedure sequence for reference
.... service 1..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... facility 0..1Reference(Location | Organization)Servicing Facility
.... diagnosis 0..*BackboneElementList of Diagnosis
..... diagnosis[x] 0..1Patient's diagnosis
ICD-10 Codes (Example)
...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)

doco Documentation for this format

UML Diagram (Legend)

EligibilityRequest (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Process Priority ?? »Patient Resourcepatient : Reference [0..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »Facility where the services were providedfacility : Reference [0..1] « Location »Financial instrument by which payment information for health carecoverage : Reference [0..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]Dental, Vision, Medical, Pharmacy, Rehab etcbenefitCategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcbenefitSubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »AuthorizationSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : CodeableConcept [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Money [0..1]Facility where the services were providedfacility : Reference [0..1] « Location|Organization »DiagnosisThe diagnosisdiagnosis[x] : Type [0..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? »List of patient diagnosis for which care is soughtdiagnosis[0..*]A list of billable services for which an authorization prior to service delivery may be required by the payorauthorization[0..*]

XML Template

<EligibilityRequest xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></provider>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <benefitCategory><!-- 0..1 CodeableConcept Type of services covered --></benefitCategory>
 <benefitSubCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></benefitSubCategory>
 <authorization>  <!-- 0..* Services which may require prior authorization -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <service><!-- 1..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>
  <diagnosis>  <!-- 0..* List of Diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  </diagnosis>
 </authorization>
</EligibilityRequest>

JSON Template

{doco
  "resourceType" : "EligibilityRequest",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "priority" : { CodeableConcept }, // Desired processing priority
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  // serviced[x]: Estimated date or dates of Service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "insurer" : { Reference(Organization) }, // Target
  "facility" : { Reference(Location) }, // Servicing Facility
  "coverage" : { Reference(Coverage) }, // Insurance or medical plan
  "businessArrangement" : "<string>", // Business agreement
  "benefitCategory" : { CodeableConcept }, // Type of services covered
  "benefitSubCategory" : { CodeableConcept }, // Detailed services covered within the type
  "authorization" : [{ // Services which may require prior authorization
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "service" : { CodeableConcept }, // R!  Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "facility" : { Reference(Location|Organization) }, // Servicing Facility
    "diagnosis" : [{ // List of Diagnosis
      // diagnosis[x]: Patient's diagnosis. One of these 2:
      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:EligibilityRequest;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityRequest.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:EligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # EligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2
    fhir:EligibilityRequest.servicedDate [ date ]
    fhir:EligibilityRequest.servicedPeriod [ Period ]
  fhir:EligibilityRequest.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:EligibilityRequest.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner
  fhir:EligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:EligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:EligibilityRequest.coverage [ Reference(Coverage) ]; # 0..1 Insurance or medical plan
  fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement
  fhir:EligibilityRequest.benefitCategory [ CodeableConcept ]; # 0..1 Type of services covered
  fhir:EligibilityRequest.benefitSubCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
  fhir:EligibilityRequest.authorization [ # 0..* Services which may require prior authorization
    fhir:EligibilityRequest.authorization.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:EligibilityRequest.authorization.service [ CodeableConcept ]; # 1..1 Billing Code
    fhir:EligibilityRequest.authorization.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:EligibilityRequest.authorization.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:EligibilityRequest.authorization.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:EligibilityRequest.authorization.facility [ Reference(Location|Organization) ]; # 0..1 Servicing Facility
    fhir:EligibilityRequest.authorization.diagnosis [ # 0..* List of Diagnosis
      # EligibilityRequest.authorization.diagnosis.diagnosis[x] : 0..1 Patient's diagnosis. One of these 2
        fhir:EligibilityRequest.authorization.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:EligibilityRequest.authorization.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
  ], ...;
]

Changes since R3

EligibilityRequest
EligibilityRequest.enterer
  • Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole)
EligibilityRequest.provider
  • Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization)
EligibilityRequest.authorization
  • Added Element
EligibilityRequest.authorization.sequence
  • Added Element
EligibilityRequest.authorization.service
  • Added Element
EligibilityRequest.authorization.modifier
  • Added Element
EligibilityRequest.authorization.quantity
  • Added Element
EligibilityRequest.authorization.unitPrice
  • Added Element
EligibilityRequest.authorization.facility
  • Added Element
EligibilityRequest.authorization.diagnosis
  • Added Element
EligibilityRequest.authorization.diagnosis.diagnosis[x]
  • Added Element
EligibilityRequest.organization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. EligibilityRequest TUDomainResourceDetermine insurance validity and scope of coverage
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... patient 0..1Reference(Patient)The subject of the Products and Services
... serviced[x] 0..1Estimated date or dates of Service
.... servicedDatedate
.... servicedPeriodPeriod
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible practitioner
... insurer 0..1Reference(Organization)Target
... facility 0..1Reference(Location)Servicing Facility
... coverage 0..1Reference(Coverage)Insurance or medical plan
... businessArrangement 0..1stringBusiness agreement
... benefitCategory 0..1CodeableConceptType of services covered
Benefit Category Codes (Example)
... benefitSubCategory 0..1CodeableConceptDetailed services covered within the type
Benefit SubCategory Codes (Example)
... authorization 0..*BackboneElementServices which may require prior authorization
.... sequence 1..1positiveIntProcedure sequence for reference
.... service 1..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... facility 0..1Reference(Location | Organization)Servicing Facility
.... diagnosis 0..*BackboneElementList of Diagnosis
..... diagnosis[x] 0..1Patient's diagnosis
ICD-10 Codes (Example)
...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)

doco Documentation for this format

UML Diagram (Legend)

EligibilityRequest (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Process Priority ?? »Patient Resourcepatient : Reference [0..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »Facility where the services were providedfacility : Reference [0..1] « Location »Financial instrument by which payment information for health carecoverage : Reference [0..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]Dental, Vision, Medical, Pharmacy, Rehab etcbenefitCategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)Benefit Category ?? »Dental: basic, major, ortho; Vision exam, glasses, contacts; etcbenefitSubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »AuthorizationSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : CodeableConcept [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Money [0..1]Facility where the services were providedfacility : Reference [0..1] « Location|Organization »DiagnosisThe diagnosisdiagnosis[x] : Type [0..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? »List of patient diagnosis for which care is soughtdiagnosis[0..*]A list of billable services for which an authorization prior to service delivery may be required by the payorauthorization[0..*]

XML Template

<EligibilityRequest xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></provider>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
 <benefitCategory><!-- 0..1 CodeableConcept Type of services covered --></benefitCategory>
 <benefitSubCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></benefitSubCategory>
 <authorization>  <!-- 0..* Services which may require prior authorization -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <service><!-- 1..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>
  <diagnosis>  <!-- 0..* List of Diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  </diagnosis>
 </authorization>
</EligibilityRequest>

JSON Template

{doco
  "resourceType" : "EligibilityRequest",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "priority" : { CodeableConcept }, // Desired processing priority
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  // serviced[x]: Estimated date or dates of Service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "insurer" : { Reference(Organization) }, // Target
  "facility" : { Reference(Location) }, // Servicing Facility
  "coverage" : { Reference(Coverage) }, // Insurance or medical plan
  "businessArrangement" : "<string>", // Business agreement
  "benefitCategory" : { CodeableConcept }, // Type of services covered
  "benefitSubCategory" : { CodeableConcept }, // Detailed services covered within the type
  "authorization" : [{ // Services which may require prior authorization
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "service" : { CodeableConcept }, // R!  Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "facility" : { Reference(Location|Organization) }, // Servicing Facility
    "diagnosis" : [{ // List of Diagnosis
      // diagnosis[x]: Patient's diagnosis. One of these 2:
      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:EligibilityRequest;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityRequest.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:EligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # EligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2
    fhir:EligibilityRequest.servicedDate [ date ]
    fhir:EligibilityRequest.servicedPeriod [ Period ]
  fhir:EligibilityRequest.created [ dateTime ]; # 0..1 Creation date
  fhir:EligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:EligibilityRequest.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner
  fhir:EligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:EligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:EligibilityRequest.coverage [ Reference(Coverage) ]; # 0..1 Insurance or medical plan
  fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement
  fhir:EligibilityRequest.benefitCategory [ CodeableConcept ]; # 0..1 Type of services covered
  fhir:EligibilityRequest.benefitSubCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
  fhir:EligibilityRequest.authorization [ # 0..* Services which may require prior authorization
    fhir:EligibilityRequest.authorization.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:EligibilityRequest.authorization.service [ CodeableConcept ]; # 1..1 Billing Code
    fhir:EligibilityRequest.authorization.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:EligibilityRequest.authorization.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:EligibilityRequest.authorization.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:EligibilityRequest.authorization.facility [ Reference(Location|Organization) ]; # 0..1 Servicing Facility
    fhir:EligibilityRequest.authorization.diagnosis [ # 0..* List of Diagnosis
      # EligibilityRequest.authorization.diagnosis.diagnosis[x] : 0..1 Patient's diagnosis. One of these 2
        fhir:EligibilityRequest.authorization.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:EligibilityRequest.authorization.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
  ], ...;
]

Changes since DSTU2

EligibilityRequest
EligibilityRequest.enterer
  • Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole)
EligibilityRequest.provider
  • Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization)
EligibilityRequest.authorization
  • Added Element
EligibilityRequest.authorization.sequence
  • Added Element
EligibilityRequest.authorization.service
  • Added Element
EligibilityRequest.authorization.modifier
  • Added Element
EligibilityRequest.authorization.quantity
  • Added Element
EligibilityRequest.authorization.unitPrice
  • Added Element
EligibilityRequest.authorization.facility
  • Added Element
EligibilityRequest.authorization.diagnosis
  • Added Element
EligibilityRequest.authorization.diagnosis.diagnosis[x]
  • Added Element
EligibilityRequest.organization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

 

Alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

PathDefinitionTypeReference
EligibilityRequest.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
EligibilityRequest.priority The timeliness with which processing is required: STAT, normal, DeferredExampleProcess Priority Codes
EligibilityRequest.benefitCategory Benefit categories such as: oral, medical, vision etc.ExampleBenefit Category Codes
EligibilityRequest.benefitSubCategory Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory Codes
EligibilityRequest.authorization.service Allowable service and product codesExampleUSCLS Codes
EligibilityRequest.authorization.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifier type Codes
EligibilityRequest.authorization.diagnosis.diagnosis[x] ICD10 Diagnostic codesExampleICD-10 Codes

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionExpressionIn Common
createddateThe creation date for the EOBEligibilityRequest.created
entererreferenceThe party who is responsible for the requestEligibilityRequest.enterer
(Practitioner, PractitionerRole)
facilityreferenceFacility responsible for the goods and servicesEligibilityRequest.facility
(Location)
identifiertokenThe business identifier of the EligibilityEligibilityRequest.identifier
patientreferenceThe reference to the patientEligibilityRequest.patient
(Patient)
providerreferenceThe reference to the providerEligibilityRequest.provider
(Practitioner, Organization, PractitionerRole)
statustokenThe status of the EligibilityRequestEligibilityRequest.status