This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
Financial Management ![]() | Maturity Level: 4 | Trial Use | Security Category: Patient | Compartments: Patient, Practitioner |
The CoverageEligibilityRequest provides patient and insurance coverage information 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.
The CoverageEligibilityRequest makes a request of an insurer asking them to provide, in the form of an CoverageEligibilityResponse, information regarding: (validation) whether the specified coverage(s) is valid and in-force; (discovery) what coverages the insurer has for the specified patient; (benefits) the benefits provided under the coverage; whether benefits exist under the specified coverage(s) for specified classes of services and products; and (auth-requirements) whether preauthorization is required, and if so what information may be required in that preauthorization, for the specified service classes or services.
The CoverageEligibilityRequest 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:
CoverageEligibilityRequest should be used 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.
The Claim resource should be used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.
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 CoverageEligibilityRequest.
The eClaim domain includes a number of related resources
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. |
Claim | A suite of goods and services and insurances coverages under which adjudication or authorization is requested. |
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. |
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 |
---|---|---|---|
CoverageEligibilityRequest.status | FinancialResourceStatusCodes | Required | This value set includes Status codes. |
CoverageEligibilityRequest.priority | ProcessPriorityCodes | Example | This value set includes the financial processing priority codes. |
CoverageEligibilityRequest.purpose | EligibilityRequestPurpose | Required | A code specifying the types of information being requested. |
CoverageEligibilityRequest.event.type | DatesTypeCodes (a valid code from Dates Event Type Codes) | Example | This value set includes sample Dates Type codes. |
CoverageEligibilityRequest.item.category | BenefitCategoryCodes | Example | This value set includes examples of Benefit Category codes. |
CoverageEligibilityRequest.item.productOrService | USCLSCodes | Example | This value set includes a smattering of USCLS codes. |
CoverageEligibilityRequest.item.modifier | ModifierTypeCodes | Example | This value set includes sample Modifier type codes. |
CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | ICD10Codes (a valid code from ICD-10 ![]() |
Example | This value set includes sample ICD-10 codes. |
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 for the EOB | CoverageEligibilityRequest.created | |
enterer | reference | The party who is responsible for the request | CoverageEligibilityRequest.enterer (Practitioner, PractitionerRole) |
|
facility | reference | Facility responsible for the goods and services | CoverageEligibilityRequest.facility (Location) |
|
identifier | token | The business identifier of the Eligibility | CoverageEligibilityRequest.identifier | 65 Resources |
patient | reference | The reference to the patient | CoverageEligibilityRequest.patient (Patient) |
65 Resources |
provider | reference | The reference to the provider | CoverageEligibilityRequest.provider (Practitioner, Organization, PractitionerRole) |
|
status | token | The status of the EligibilityRequest | CoverageEligibilityRequest.status |