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Financial Management icon Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Patient, Practitioner

Detailed Descriptions for the elements in the CoverageEligibilityResponse resource.

CoverageEligibilityResponse
Element IdCoverageEligibilityResponse
Definition

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

Short DisplayCoverageEligibilityResponse resource
Cardinality0..*
TypeDomainResource
Summaryfalse
CoverageEligibilityResponse.identifier
Element IdCoverageEligibilityResponse.identifier
Definition

A unique identifier assigned to this coverage eligiblity request.

Short DisplayBusiness Identifier for coverage eligiblity request
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

Allows coverage eligibility requests to be distinguished and referenced.

Summaryfalse
CoverageEligibilityResponse.status
Element IdCoverageEligibilityResponse.status
Definition

The status of the resource instance.

Short Displayactive | cancelled | draft | entered-in-error
Cardinality1..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

CoverageEligibilityResponse.purpose
Element IdCoverageEligibilityResponse.purpose
Definition

Code to specify whether requesting: prior authorization requirements for some service categories or billing codes; benefits for coverages specified or discovered; discovery and return of coverages for the patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.

Short Displayauth-requirements | benefits | discovery | validation
Cardinality1..*
Terminology BindingEligibilityResponsePurpose (Required)
Typecode
Requirements

To indicate the processing actions requested.

Summarytrue
CoverageEligibilityResponse.patient
Element IdCoverageEligibilityResponse.patient
Definition

The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.

Short DisplayIntended recipient of products and services
Cardinality1..1
TypeReference(Patient)
Requirements

Required to provide context and coverage validation.

Summarytrue
CoverageEligibilityResponse.serviced[x]
Element IdCoverageEligibilityResponse.serviced[x]
Definition

The date or dates when the enclosed suite of services were performed or completed.

Short DisplayEstimated date or dates of service
Cardinality0..1
Typedate|Period
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Required to provide time context for the request.

Summaryfalse
CoverageEligibilityResponse.created
Element IdCoverageEligibilityResponse.created
Definition

The date this resource was created.

Short DisplayResponse creation date
Cardinality1..1
TypedateTime
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Summarytrue
CoverageEligibilityResponse.requestor
Element IdCoverageEligibilityResponse.requestor
Definition

The provider which is responsible for the request.

Short DisplayParty responsible for the request
Cardinality0..1
TypeReference(Practitioner | PractitionerRole | Organization)
Summaryfalse
Comments

This party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.

CoverageEligibilityResponse.request
Element IdCoverageEligibilityResponse.request
Definition

Reference to the original request resource.

Short DisplayEligibility request reference
Cardinality1..1
TypeReference(CoverageEligibilityRequest)
Requirements

Needed to allow the response to be linked to the request.

Summarytrue
CoverageEligibilityResponse.outcome
Element IdCoverageEligibilityResponse.outcome
Definition

The outcome of the request processing.

Short Displayqueued | complete | error | partial
Cardinality1..1
Terminology BindingEligibilityOutcome (Required)
Typecode
Requirements

To advise the requestor of an overall processing outcome.

Summarytrue
Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

CoverageEligibilityResponse.disposition
Element IdCoverageEligibilityResponse.disposition
Definition

A human readable description of the status of the adjudication.

Short DisplayDisposition Message
Cardinality0..1
Typestring
Requirements

Provided for user display.

Summaryfalse
CoverageEligibilityResponse.insurer
Element IdCoverageEligibilityResponse.insurer
Definition

The Insurer who issued the coverage in question and is the author of the response.

Short DisplayCoverage issuer
Cardinality1..1
TypeReference(Organization)
Requirements

Need to identify the author.

Summarytrue
CoverageEligibilityResponse.insurance
Element IdCoverageEligibilityResponse.insurance
Definition

Financial instruments for reimbursement for the health care products and services.

Short DisplayPatient insurance information
Cardinality0..*
Requirements

There must be at least one coverage for which eligibility is requested.

Summaryfalse
Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

CoverageEligibilityResponse.insurance.coverage
Element IdCoverageEligibilityResponse.insurance.coverage
Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Short DisplayInsurance information
Cardinality1..1
TypeReference(Coverage)
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Summarytrue
CoverageEligibilityResponse.insurance.inforce
Element IdCoverageEligibilityResponse.insurance.inforce
Definition

Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.

Short DisplayCoverage inforce indicator
Cardinality0..1
Typeboolean
Requirements

Needed to convey the answer to the eligibility validation request.

Summaryfalse
CoverageEligibilityResponse.insurance.benefitPeriod
Element IdCoverageEligibilityResponse.insurance.benefitPeriod
Definition

The term of the benefits documented in this response.

Short DisplayWhen the benefits are applicable
Cardinality0..1
TypePeriod
Requirements

Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

Summaryfalse
CoverageEligibilityResponse.insurance.item
Element IdCoverageEligibilityResponse.insurance.item
Definition

Benefits and optionally current balances, and authorization details by category or service.

Short DisplayBenefits and authorization details
Cardinality0..*
Summaryfalse
Invariants
Defined on this element
ces-1Rule SHALL contain a category or a billcode but not both.category.exists() xor productOrService.exists()
CoverageEligibilityResponse.insurance.item.category
Element IdCoverageEligibilityResponse.insurance.item.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Short DisplayBenefit classification
Cardinality0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the category of service or product for which eligibility is sought.

Summaryfalse
Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

CoverageEligibilityResponse.insurance.item.productOrService
Element IdCoverageEligibilityResponse.insurance.item.productOrService
Definition

This contains the product, service, drug or other billing code for the item.

Short DisplayBilling, service, product, or drug code
Cardinality0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the actual service or product for which eligibility is sought.

Alternate NamesDrug Code; Bill Code; Service Code
Summaryfalse
Comments

Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).

CoverageEligibilityResponse.insurance.item.modifier
Element IdCoverageEligibilityResponse.insurance.item.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Short DisplayProduct or service billing modifiers
Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support provision of the item or to charge an elevated fee.

Summaryfalse
Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

CoverageEligibilityResponse.insurance.item.provider
Element IdCoverageEligibilityResponse.insurance.item.provider
Definition

The practitioner who is eligible for the provision of the product or service.

Short DisplayPerforming practitioner
Cardinality0..1
TypeReference(Practitioner | PractitionerRole)
Requirements

Needed to convey the eligible provider.

Summaryfalse
CoverageEligibilityResponse.insurance.item.excluded
Element IdCoverageEligibilityResponse.insurance.item.excluded
Definition

True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

Short DisplayExcluded from the plan
Cardinality0..1
Typeboolean
Requirements

Needed to identify items that are specifically excluded from the coverage.

Summaryfalse
CoverageEligibilityResponse.insurance.item.name
Element IdCoverageEligibilityResponse.insurance.item.name
Definition

A short name or tag for the benefit.

Short DisplayShort name for the benefit
Cardinality0..1
Typestring
Requirements

Required to align with other plan names.

Summaryfalse
Comments

For example: MED01, or DENT2.

CoverageEligibilityResponse.insurance.item.description
Element IdCoverageEligibilityResponse.insurance.item.description
Definition

A richer description of the benefit or services covered.

Short DisplayDescription of the benefit or services covered
Cardinality0..1
Typestring
Requirements

Needed for human readable reference.

Summaryfalse
Comments

For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

CoverageEligibilityResponse.insurance.item.network
Element IdCoverageEligibilityResponse.insurance.item.network
Definition

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Short DisplayIn or out of network
Cardinality0..1
Terminology BindingNetwork Type Codes (Example)
TypeCodeableConcept
Requirements

Needed as in or out of network providers are treated differently under the coverage.

Summaryfalse
CoverageEligibilityResponse.insurance.item.unit
Element IdCoverageEligibilityResponse.insurance.item.unit
Definition

Indicates if the benefits apply to an individual or to the family.

Short DisplayIndividual or family
Cardinality0..1
Terminology BindingUnit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

Summaryfalse
CoverageEligibilityResponse.insurance.item.term
Element IdCoverageEligibilityResponse.insurance.item.term
Definition

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Short DisplayAnnual or lifetime
Cardinality0..1
Terminology BindingBenefit Term Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

Summaryfalse
CoverageEligibilityResponse.insurance.item.benefit
Element IdCoverageEligibilityResponse.insurance.item.benefit
Definition

Benefits used to date.

Short DisplayBenefit Summary
Cardinality0..*
Summaryfalse
CoverageEligibilityResponse.insurance.item.benefit.type
Element IdCoverageEligibilityResponse.insurance.item.benefit.type
Definition

Classification of benefit being provided.

Short DisplayBenefit classification
Cardinality1..1
Terminology BindingBenefit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the nature of the benefit.

Summaryfalse
Comments

For example: deductible, visits, benefit amount.

CoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Element IdCoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Definition

The quantity of the benefit which is permitted under the coverage.

Short DisplayBenefits allowed
Cardinality0..1
TypeunsignedInt|string|Money
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Needed to convey the benefits offered under the coverage.

Summaryfalse
CoverageEligibilityResponse.insurance.item.benefit.used[x]
Element IdCoverageEligibilityResponse.insurance.item.benefit.used[x]
Definition

The quantity of the benefit which have been consumed to date.

Short DisplayBenefits used
Cardinality0..1
TypeunsignedInt|string|Money
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Needed to convey the benefits consumed to date.

Summaryfalse
CoverageEligibilityResponse.insurance.item.authorizationRequired
Element IdCoverageEligibilityResponse.insurance.item.authorizationRequired
Definition

A boolean flag indicating whether a preauthorization is required prior to actual service delivery.

Short DisplayAuthorization required flag
Cardinality0..1
Typeboolean
Requirements

Needed to convey that preauthorization is required.

Summaryfalse
CoverageEligibilityResponse.insurance.item.authorizationSupporting
Element IdCoverageEligibilityResponse.insurance.item.authorizationSupporting
Definition

Codes or comments regarding information or actions associated with the preauthorization.

Short DisplayType of required supporting materials
Cardinality0..*
Terminology BindingCoverageEligibilityResponse Auth Support Codes (Example)
TypeCodeableConcept
Requirements

Needed to inform the provider of collateral materials or actions needed for preauthorization.

Summaryfalse
CoverageEligibilityResponse.insurance.item.authorizationUrl
Element IdCoverageEligibilityResponse.insurance.item.authorizationUrl
Definition

A web location for obtaining requirements or descriptive information regarding the preauthorization.

Short DisplayPreauthorization requirements endpoint
Cardinality0..1
Typeuri
Requirements

Needed to enable insurers to advise providers of informative information.

Summaryfalse
CoverageEligibilityResponse.preAuthRef
Element IdCoverageEligibilityResponse.preAuthRef
Definition

A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.

Short DisplayPreauthorization reference
Cardinality0..1
Typestring
Requirements

To provide any preauthorization reference for provider use.

Summaryfalse
CoverageEligibilityResponse.form
Element IdCoverageEligibilityResponse.form
Definition

A code for the form to be used for printing the content.

Short DisplayPrinted form identifier
Cardinality0..1
Terminology BindingForm Codes (Example)
TypeCodeableConcept
Requirements

Needed to specify the specific form used for producing output for this response.

Summaryfalse
Comments

May be needed to identify specific jurisdictional forms.

CoverageEligibilityResponse.error
Element IdCoverageEligibilityResponse.error
Definition

Errors encountered during the processing of the request.

Short DisplayProcessing errors
Cardinality0..*
Requirements

Need to communicate processing issues to the requestor.

Summaryfalse
CoverageEligibilityResponse.error.code
Element IdCoverageEligibilityResponse.error.code
Definition

An error code,from a specified code system, which details why the eligibility check could not be performed.

Short DisplayError code detailing processing issues
Cardinality1..1
Terminology BindingAdjudication Error Codes (Example)
TypeCodeableConcept
Requirements

Required to convey processing errors.

Summaryfalse