This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
Financial Management Work Group | Maturity Level: 4 | Trial Use | Security Category: Patient | Compartments: Patient, Practitioner |
This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.
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.
Additional information regarding electronic coverage eligibility content and usage may be found at:
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. |
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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) |
patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services |
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 |
Documentation for this format |
See the Extensions for this resource
UML Diagram (Legend)
XML Template
<CoverageEligibilityResponse xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier> <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error --> <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation --> <patient><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient> <event> <!-- 0..* Event information --> <type><!-- 1..1 CodeableConcept Specific event --></type> <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]> </event> <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]> <created value="[dateTime]"/><!-- 1..1 Response creation date --> <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></requestor> <request><!-- 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference --></request> <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial --> <disposition value="[string]"/><!-- 0..1 Disposition Message --> <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer> <insurance> <!-- 0..* Patient insurance information --> <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage> <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator --> <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod> <item> <!-- 0..* Benefits and authorization details --> <category><!-- I 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- I 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier> <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Performing practitioner --></provider> <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan --> <name value="[string]"/><!-- 0..1 Short name for the benefit --> <description value="[string]"/><!-- 0..1 Description of the benefit or services covered --> <network><!-- 0..1 CodeableConcept In or out of network --></network> <unit><!-- 0..1 CodeableConcept Individual or family --></unit> <term><!-- 0..1 CodeableConcept Annual or lifetime --></term> <benefit> <!-- 0..* Benefit Summary --> <type><!-- 1..1 CodeableConcept Benefit classification --></type> <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]> <used[x]><!-- 0..1 unsignedInt|string|Money Benefits used --></used[x]> </benefit> <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag --> <authorizationSupporting><!-- 0..* CodeableConcept Type of required supporting materials --></authorizationSupporting> <authorizationUrl value="[uri]"/><!-- 0..1 Preauthorization requirements endpoint --> </item> </insurance> <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference --> <form><!-- 0..1 CodeableConcept Printed form identifier --></form> <error> <!-- 0..* Processing errors --> <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code> <expression value="[string]"/><!-- 0..* FHIRPath of element(s) related to issue --> </error> </CoverageEligibilityResponse>
JSON Template
{ "resourceType" : "CoverageEligibilityResponse", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request "status" : "<code>", // R! active | cancelled | draft | entered-in-error "purpose" : ["<code>"], // R! auth-requirements | benefits | discovery | validation "patient" : { Reference(Patient) }, // R! Intended recipient of products and services "event" : [{ // Event information "type" : { CodeableConcept }, // R! Specific event // when[x]: Occurance date or period. One of these 2: "whenDateTime" : "<dateTime>", "whenPeriod" : { Period } }], // serviced[x]: Estimated date or dates of service. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, "created" : "<dateTime>", // R! Response creation date "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request "request" : { Reference(CoverageEligibilityRequest) }, // R! Eligibility request reference "outcome" : "<code>", // R! queued | complete | error | partial "disposition" : "<string>", // Disposition Message "insurer" : { Reference(Organization) }, // R! Coverage issuer "insurance" : [{ // Patient insurance information "coverage" : { Reference(Coverage) }, // R! Insurance information "inforce" : <boolean>, // Coverage inforce indicator "benefitPeriod" : { Period }, // When the benefits are applicable "item" : [{ // Benefits and authorization details "category" : { CodeableConcept }, // I Benefit classification "productOrService" : { CodeableConcept }, // I Billing, service, product, or drug code "modifier" : [{ CodeableConcept }], // Product or service billing modifiers "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner "excluded" : <boolean>, // Excluded from the plan "name" : "<string>", // Short name for the benefit "description" : "<string>", // Description of the benefit or services covered "network" : { CodeableConcept }, // In or out of network "unit" : { CodeableConcept }, // Individual or family "term" : { CodeableConcept }, // Annual or lifetime "benefit" : [{ // Benefit Summary "type" : { CodeableConcept }, // R! Benefit classification // allowed[x]: Benefits allowed. One of these 3: "allowedUnsignedInt" : "<unsignedInt>", "allowedString" : "<string>", "allowedMoney" : { Money }, // used[x]: Benefits used. One of these 3: "usedUnsignedInt" : "<unsignedInt>", "usedString" : "<string>", "usedMoney" : { Money } }], "authorizationRequired" : <boolean>, // Authorization required flag "authorizationSupporting" : [{ CodeableConcept }], // Type of required supporting materials "authorizationUrl" : "<uri>" // Preauthorization requirements endpoint }] }], "preAuthRef" : "<string>", // Preauthorization reference "form" : { CodeableConcept }, // Printed form identifier "error" : [{ // Processing errors "code" : { CodeableConcept }, // R! Error code detailing processing issues "expression" : ["<string>"] // FHIRPath of element(s) related to issue }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:CoverageEligibilityResponse; 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:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for coverage eligiblity request fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error fhir:purpose ( [ code ] ... ) ; # 1..* auth-requirements | benefits | discovery | validation fhir:patient [ Reference(Patient) ] ; # 1..1 Intended recipient of products and services fhir:event ( [ # 0..* Event information fhir:type [ CodeableConcept ] ; # 1..1 Specific event # when[x] : 1..1 Occurance date or period. One of these 2 fhir:when [ a fhir:dateTime ; dateTime ] fhir:when [ a fhir:Period ; Period ] ] ... ) ; # serviced[x] : 0..1 Estimated date or dates of service. One of these 2 fhir:serviced [ a fhir:date ; date ] fhir:serviced [ a fhir:Period ; Period ] fhir:created [ dateTime ] ; # 1..1 Response creation date fhir:requestor [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the request fhir:request [ Reference(CoverageEligibilityRequest) ] ; # 1..1 Eligibility request reference fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial fhir:disposition [ string ] ; # 0..1 Disposition Message fhir:insurer [ Reference(Organization) ] ; # 1..1 Coverage issuer fhir:insurance ( [ # 0..* Patient insurance information fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information fhir:inforce [ boolean ] ; # 0..1 Coverage inforce indicator fhir:benefitPeriod [ Period ] ; # 0..1 When the benefits are applicable fhir:item ( [ # 0..* Benefits and authorization details fhir:category [ CodeableConcept ] ; # 0..1 I Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 I Billing, service, product, or drug code fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers fhir:provider [ Reference(Practitioner|PractitionerRole) ] ; # 0..1 Performing practitioner fhir:excluded [ boolean ] ; # 0..1 Excluded from the plan fhir:name [ string ] ; # 0..1 Short name for the benefit fhir:description [ string ] ; # 0..1 Description of the benefit or services covered fhir:network [ CodeableConcept ] ; # 0..1 In or out of network fhir:unit [ CodeableConcept ] ; # 0..1 Individual or family fhir:term [ CodeableConcept ] ; # 0..1 Annual or lifetime fhir:benefit ( [ # 0..* Benefit Summary fhir:type [ CodeableConcept ] ; # 1..1 Benefit classification # allowed[x] : 0..1 Benefits allowed. One of these 3 fhir:allowed [ a fhir:unsignedInt ; unsignedInt ] fhir:allowed [ a fhir:string ; string ] fhir:allowed [ a fhir:Money ; Money ] # used[x] : 0..1 Benefits used. One of these 3 fhir:used [ a fhir:unsignedInt ; unsignedInt ] fhir:used [ a fhir:string ; string ] fhir:used [ a fhir:Money ; Money ] ] ... ) ; fhir:authorizationRequired [ boolean ] ; # 0..1 Authorization required flag fhir:authorizationSupporting ( [ CodeableConcept ] ... ) ; # 0..* Type of required supporting materials fhir:authorizationUrl [ uri ] ; # 0..1 Preauthorization requirements endpoint ] ... ) ; ] ... ) ; fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference fhir:form [ CodeableConcept ] ; # 0..1 Printed form identifier fhir:error ( [ # 0..* Processing errors fhir:code [ CodeableConcept ] ; # 1..1 Error code detailing processing issues fhir:expression ( [ string ] ... ) ; # 0..* FHIRPath of element(s) related to issue ] ... ) ; ]
Changes from both R4 and R4B
CoverageEligibilityResponse | |
CoverageEligibilityResponse.event |
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CoverageEligibilityResponse.event.type |
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CoverageEligibilityResponse.event.when[x] |
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CoverageEligibilityResponse.outcome |
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CoverageEligibilityResponse.error.expression |
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See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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) |
patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services |
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 |
Documentation for this format |
See the Extensions for this resource
XML Template
<CoverageEligibilityResponse xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier> <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error --> <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation --> <patient><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient> <event> <!-- 0..* Event information --> <type><!-- 1..1 CodeableConcept Specific event --></type> <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]> </event> <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]> <created value="[dateTime]"/><!-- 1..1 Response creation date --> <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></requestor> <request><!-- 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference --></request> <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial --> <disposition value="[string]"/><!-- 0..1 Disposition Message --> <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer> <insurance> <!-- 0..* Patient insurance information --> <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage> <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator --> <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod> <item> <!-- 0..* Benefits and authorization details --> <category><!-- I 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- I 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier> <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Performing practitioner --></provider> <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan --> <name value="[string]"/><!-- 0..1 Short name for the benefit --> <description value="[string]"/><!-- 0..1 Description of the benefit or services covered --> <network><!-- 0..1 CodeableConcept In or out of network --></network> <unit><!-- 0..1 CodeableConcept Individual or family --></unit> <term><!-- 0..1 CodeableConcept Annual or lifetime --></term> <benefit> <!-- 0..* Benefit Summary --> <type><!-- 1..1 CodeableConcept Benefit classification --></type> <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]> <used[x]><!-- 0..1 unsignedInt|string|Money Benefits used --></used[x]> </benefit> <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag --> <authorizationSupporting><!-- 0..* CodeableConcept Type of required supporting materials --></authorizationSupporting> <authorizationUrl value="[uri]"/><!-- 0..1 Preauthorization requirements endpoint --> </item> </insurance> <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference --> <form><!-- 0..1 CodeableConcept Printed form identifier --></form> <error> <!-- 0..* Processing errors --> <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code> <expression value="[string]"/><!-- 0..* FHIRPath of element(s) related to issue --> </error> </CoverageEligibilityResponse>
JSON Template
{ "resourceType" : "CoverageEligibilityResponse", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request "status" : "<code>", // R! active | cancelled | draft | entered-in-error "purpose" : ["<code>"], // R! auth-requirements | benefits | discovery | validation "patient" : { Reference(Patient) }, // R! Intended recipient of products and services "event" : [{ // Event information "type" : { CodeableConcept }, // R! Specific event // when[x]: Occurance date or period. One of these 2: "whenDateTime" : "<dateTime>", "whenPeriod" : { Period } }], // serviced[x]: Estimated date or dates of service. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, "created" : "<dateTime>", // R! Response creation date "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request "request" : { Reference(CoverageEligibilityRequest) }, // R! Eligibility request reference "outcome" : "<code>", // R! queued | complete | error | partial "disposition" : "<string>", // Disposition Message "insurer" : { Reference(Organization) }, // R! Coverage issuer "insurance" : [{ // Patient insurance information "coverage" : { Reference(Coverage) }, // R! Insurance information "inforce" : <boolean>, // Coverage inforce indicator "benefitPeriod" : { Period }, // When the benefits are applicable "item" : [{ // Benefits and authorization details "category" : { CodeableConcept }, // I Benefit classification "productOrService" : { CodeableConcept }, // I Billing, service, product, or drug code "modifier" : [{ CodeableConcept }], // Product or service billing modifiers "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner "excluded" : <boolean>, // Excluded from the plan "name" : "<string>", // Short name for the benefit "description" : "<string>", // Description of the benefit or services covered "network" : { CodeableConcept }, // In or out of network "unit" : { CodeableConcept }, // Individual or family "term" : { CodeableConcept }, // Annual or lifetime "benefit" : [{ // Benefit Summary "type" : { CodeableConcept }, // R! Benefit classification // allowed[x]: Benefits allowed. One of these 3: "allowedUnsignedInt" : "<unsignedInt>", "allowedString" : "<string>", "allowedMoney" : { Money }, // used[x]: Benefits used. One of these 3: "usedUnsignedInt" : "<unsignedInt>", "usedString" : "<string>", "usedMoney" : { Money } }], "authorizationRequired" : <boolean>, // Authorization required flag "authorizationSupporting" : [{ CodeableConcept }], // Type of required supporting materials "authorizationUrl" : "<uri>" // Preauthorization requirements endpoint }] }], "preAuthRef" : "<string>", // Preauthorization reference "form" : { CodeableConcept }, // Printed form identifier "error" : [{ // Processing errors "code" : { CodeableConcept }, // R! Error code detailing processing issues "expression" : ["<string>"] // FHIRPath of element(s) related to issue }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:CoverageEligibilityResponse; 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:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for coverage eligiblity request fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error fhir:purpose ( [ code ] ... ) ; # 1..* auth-requirements | benefits | discovery | validation fhir:patient [ Reference(Patient) ] ; # 1..1 Intended recipient of products and services fhir:event ( [ # 0..* Event information fhir:type [ CodeableConcept ] ; # 1..1 Specific event # when[x] : 1..1 Occurance date or period. One of these 2 fhir:when [ a fhir:dateTime ; dateTime ] fhir:when [ a fhir:Period ; Period ] ] ... ) ; # serviced[x] : 0..1 Estimated date or dates of service. One of these 2 fhir:serviced [ a fhir:date ; date ] fhir:serviced [ a fhir:Period ; Period ] fhir:created [ dateTime ] ; # 1..1 Response creation date fhir:requestor [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the request fhir:request [ Reference(CoverageEligibilityRequest) ] ; # 1..1 Eligibility request reference fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial fhir:disposition [ string ] ; # 0..1 Disposition Message fhir:insurer [ Reference(Organization) ] ; # 1..1 Coverage issuer fhir:insurance ( [ # 0..* Patient insurance information fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information fhir:inforce [ boolean ] ; # 0..1 Coverage inforce indicator fhir:benefitPeriod [ Period ] ; # 0..1 When the benefits are applicable fhir:item ( [ # 0..* Benefits and authorization details fhir:category [ CodeableConcept ] ; # 0..1 I Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 I Billing, service, product, or drug code fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers fhir:provider [ Reference(Practitioner|PractitionerRole) ] ; # 0..1 Performing practitioner fhir:excluded [ boolean ] ; # 0..1 Excluded from the plan fhir:name [ string ] ; # 0..1 Short name for the benefit fhir:description [ string ] ; # 0..1 Description of the benefit or services covered fhir:network [ CodeableConcept ] ; # 0..1 In or out of network fhir:unit [ CodeableConcept ] ; # 0..1 Individual or family fhir:term [ CodeableConcept ] ; # 0..1 Annual or lifetime fhir:benefit ( [ # 0..* Benefit Summary fhir:type [ CodeableConcept ] ; # 1..1 Benefit classification # allowed[x] : 0..1 Benefits allowed. One of these 3 fhir:allowed [ a fhir:unsignedInt ; unsignedInt ] fhir:allowed [ a fhir:string ; string ] fhir:allowed [ a fhir:Money ; Money ] # used[x] : 0..1 Benefits used. One of these 3 fhir:used [ a fhir:unsignedInt ; unsignedInt ] fhir:used [ a fhir:string ; string ] fhir:used [ a fhir:Money ; Money ] ] ... ) ; fhir:authorizationRequired [ boolean ] ; # 0..1 Authorization required flag fhir:authorizationSupporting ( [ CodeableConcept ] ... ) ; # 0..* Type of required supporting materials fhir:authorizationUrl [ uri ] ; # 0..1 Preauthorization requirements endpoint ] ... ) ; ] ... ) ; fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference fhir:form [ CodeableConcept ] ; # 0..1 Printed form identifier fhir:error ( [ # 0..* Processing errors fhir:code [ CodeableConcept ] ; # 1..1 Error code detailing processing issues fhir:expression ( [ string ] ... ) ; # 0..* FHIRPath of element(s) related to issue ] ... ) ; ]
Changes from both R4 and R4B
CoverageEligibilityResponse | |
CoverageEligibilityResponse.event |
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CoverageEligibilityResponse.event.type |
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CoverageEligibilityResponse.event.when[x] |
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CoverageEligibilityResponse.outcome |
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CoverageEligibilityResponse.error.expression |
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See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis
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. |
UniqueKey | Level | Location | Description | Expression |
ces-1 | Rule | CoverageEligibilityResponse.insurance.item | SHALL contain a category or a billcode but not both. | category.exists() xor productOrService.exists() |
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) |
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requestor | reference | The EligibilityRequest provider | CoverageEligibilityResponse.requestor (Practitioner, Organization, PractitionerRole) |
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status | token | The EligibilityRequest status | CoverageEligibilityResponse.status |