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13.2 Resource CoverageEligibilityRequest - Content

Financial Management icon Work GroupMaturity Level: 4 Trial UseSecurity 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:

  • 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.

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.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityRequest TU DomainResource CoverageEligibilityRequest 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)
... priority 0..1 CodeableConcept Desired processing priority
Binding: Process Priority Codes (Example)
... 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 Creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author
... provider 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... insurer Σ 1..1 Reference(Organization) Coverage issuer
... facility 0..1 Reference(Location) Servicing facility
... supportingInfo 0..* BackboneElement Supporting information

.... sequence 1..1 positiveInt Information instance identifier
.... information 1..1 Reference(Any) Data to be provided
.... appliesToAll 0..1 boolean Applies to all items
... insurance 0..* BackboneElement Patient insurance information

.... focal 0..1 boolean Applicable coverage
.... coverage 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
... item 0..* BackboneElement Item to be evaluated for eligibiity

.... supportingInfoSequence 0..* positiveInt Applicable exception or supporting information

.... category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes (Example)
.... productOrService 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) Perfoming practitioner
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... facility 0..1 Reference(Location | Organization) Servicing facility
.... diagnosis 0..* BackboneElement Applicable diagnosis

..... diagnosis[x] 0..1 Nature of illness or problem
Binding: ICD-10 Codes (Example)
...... diagnosisCodeableConcept CodeableConcept
...... diagnosisReference Reference(Condition)
.... detail 0..* Reference(Any) Product or service details


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

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 icon) 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