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13.3 Resource CoverageEligibilityResponse - Content

Financial Management icon Work GroupMaturity Level: 4 Trial UseSecurity Category: Patient Compartments: Patient, Practitioner

This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.

13.3.1 Scope and Usage

The CoverageEligibilityResponse resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy benefit details as well as the ability for the insurer to indicate whether the insurance provides benefits for requested types of services or requires preauthorization and if so what supporting information may be required.

The CoverageEligibilityResponse resource is a "event" resource from a FHIR workflow perspective - see Workflow Event.

13.3.1.1 Additional Information

Additional information regarding electronic coverage eligibility content and usage may be found at:

  • Financial Resource Status Lifecycle: how .status is used in the financial resources.
  • Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
  • Batches: how eClaims may handle batches of eligibility, claims and responses.
  • Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This includes how payors how request additional supporting information from providers.

13.3.2 Boundaries and Relationships

CoverageEligibilityResponse should be used to respond to a request on whether the patient's coverage is inforce, whether it is valid at this or a specified date, or to report the benefit details or preauthorization requirements associated with a coverage.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityRequest should be used instead.

The ClaimResponse resource is an insurer's adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages.

For reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used .

The Coverage resource contains the information typically found on the health insurance card for an individual used to identify the covered individual to the insurer and is referred to by the CoverageEligibilityResponse.

The eClaim domain includes a number of related resources

CoverageEligibilityResponse Patient and insurance coverage information provided to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
CoverageEligibilityRequest Patient and insurance coverage information provided to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
Coverage Provides the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.

13.3.3 References to this Resource

13.3.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse TU DomainResource CoverageEligibilityResponse resource

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..* Identifier Business Identifier for coverage eligiblity request

... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: Eligibility Response Purpose (Required)

... event 0..* BackboneElement Event information

.... type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... serviced[x] 0..1 Estimated date or dates of service
.... servicedDate date
.... servicedPeriod Period
... created Σ 1..1 dateTime Response creation date
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request Σ 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: Eligibility Outcome (Required)
... disposition 0..1 string Disposition Message
... insurer Σ 1..1 Reference(Organization) Coverage issuer
... insurance 0..* BackboneElement Patient insurance information

.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... inforce 0..1 boolean Coverage inforce indicator
.... benefitPeriod 0..1 Period When the benefits are applicable
.... item C 0..* BackboneElement Benefits and authorization details
+ Rule: SHALL contain a category or a billcode but not both.

..... category C 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes (Example)
..... productOrService C 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes (Example)
..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: Modifier type Codes (Example)

..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Excluded from the plan
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 0..1 CodeableConcept In or out of network
Binding: Network Type Codes (Example)
..... unit 0..1 CodeableConcept Individual or family
Binding: Unit Type Codes (Example)
..... term 0..1 CodeableConcept Annual or lifetime
Binding: Benefit Term Codes (Example)
..... benefit 0..* BackboneElement Benefit Summary

...... type 1..1 CodeableConcept Benefit classification
Binding: Benefit Type Codes (Example)
...... allowed[x] 0..1 Benefits allowed
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
...... used[x] 0..1 Benefits used
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponse Auth Support Codes (Example)

..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (Example)
... error 0..* BackboneElement Processing errors

.... code Σ 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (Example)
.... expression Σ 0..* string FHIRPath of element(s) related to issue


doco Documentation for this format icon

See the Extensions for this resource

 

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

13.3.4.1 Terminology Bindings

Path ValueSet Type Documentation
CoverageEligibilityResponse.status FinancialResourceStatusCodes Required

This value set includes Status codes.
CoverageEligibilityResponse.purpose EligibilityResponsePurpose Required

A code specifying the types of information being requested.
CoverageEligibilityResponse.event.type DatesTypeCodes (a valid code from Dates Event Type Codes) Example

This value set includes sample Dates Type codes.
CoverageEligibilityResponse.outcome EligibilityOutcome (a valid code from Claim Processing Codes) Required

The outcome of the processing.
CoverageEligibilityResponse.insurance.item.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
CoverageEligibilityResponse.insurance.item.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
CoverageEligibilityResponse.insurance.item.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
CoverageEligibilityResponse.insurance.item.network NetworkTypeCodes Example

This value set includes a smattering of Network type codes.
CoverageEligibilityResponse.insurance.item.unit UnitTypeCodes Example

This value set includes a smattering of Unit type codes.
CoverageEligibilityResponse.insurance.item.term BenefitTermCodes Example

This value set includes a smattering of Benefit Term codes.
CoverageEligibilityResponse.insurance.item.benefit.type BenefitTypeCodes Example

This value set includes a smattering of Benefit type codes.
CoverageEligibilityResponse.insurance.item.authorizationSupporting CoverageEligibilityResponseAuthSupportCodes Example

This value set includes CoverageEligibilityResponse Auth Support codes.
CoverageEligibilityResponse.form FormCodes Example

This value set includes a sample set of Forms codes.
CoverageEligibilityResponse.error.code AdjudicationErrorCodes Example

This value set includes a smattering of adjudication codes.

13.3.4.2 Constraints

UniqueKeyLevelLocationDescriptionExpression
img ces-1Rule CoverageEligibilityResponse.insurance.itemSHALL contain a category or a billcode but not both.category.exists() xor productOrService.exists()



13.3.5 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
created date The creation date CoverageEligibilityResponse.created
disposition string The contents of the disposition message CoverageEligibilityResponse.disposition
identifier token The business identifier CoverageEligibilityResponse.identifier 65 Resources
insurer reference The organization which generated this resource CoverageEligibilityResponse.insurer
(Organization)
outcome token The processing outcome CoverageEligibilityResponse.outcome
patient reference The reference to the patient CoverageEligibilityResponse.patient
(Patient)		 65 Resources
request reference The EligibilityRequest reference CoverageEligibilityResponse.request
(CoverageEligibilityRequest)
requestor reference The EligibilityRequest provider CoverageEligibilityResponse.requestor
(Practitioner, Organization, PractitionerRole)
status token The EligibilityRequest status CoverageEligibilityResponse.status