Finance and Insurance Service (FAIS)
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Finance and Insurance Service (FAIS), published by IHE IT Infrastructure Technical Committee. This guide is not an authorized publication; it is the continuous build for version 1.0.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/ITI.Finance/ and changes regularly. See the Directory of published versions

2:3.125 Check Coverage Eligibility Status [ITI-125]

This section corresponds to transaction [ITI-125] of the IHE IT Infrastructure Technical Framework. Transaction [ITI-125] is used by the Claims Manager and Coverage Requestor Actors. The Check Coverage Eligibility Status [ITI-125] transaction is used to get the status of a coverage eligibility request by searching for CoverageEligibilityResponse resources.

2:3.125.1 Scope

This transaction is used by the Coverage Requestor to get the status of a coverage eligibility request from a CoverageEligibilityResponse resource based on criteria it provides in the query parameters of the request message, or to retrieve a specific CoverageEligibilityResponse. The request is received by the Claims Manager. The Claims Manager processes the request and returns a response of the matching response resources.

2:3.125.2 Actor Roles

Table 2:3.125.2-1: Actor Roles

Actor Role
Coverage Requestor Requests CoverageEligibilityResponse(s) matching the supplied set of criteria from the Claims Manager.
Claims Manager Returns information for CoverageEligibilityResponse(s) matching the criteria provided by the Coverage Requestor.

2:3.125.3 Referenced Standards

2:3.125.4 Messages

Coverage RequestorClaims Manager[1]Search Coverage Eligibility Response Request:HTTP GET <Base>/CoverageEligibilityResponse?<Parameters>[2]Search Coverage Eligibility Response Response:Bundle[4]Read Coverage Eligibility Response Request:HTTP GET <Base>/CoverageEligibilityResponse/<ResourceId>[5]Read Coverage Eligibility Response Response:CoverageEligibilityResponse
Figure 2:3.125.4-1: Interaction Diagram


2:3.125.4.1 Search Coverage Eligibility Response Request Message

The Search Coverage Eligibility Response message is a FHIR search interaction on the CoverageEligibilityResponse Resource.

2:3.125.4.1.1 Trigger Events

A Coverage Requestor triggers a Search Coverage Eligibility Response Request to a Claims Manager according to the business rules for the search. These business rules are outside the scope of this transaction.

2:3.125.4.1.2 Message Semantics

A Coverage Requestor initiates a search interaction using HTTP GET as defined at http://hl7.org/fhir/R4/http.html#search on the CoverageEligibilityResponse resource. The query parameters are identified below. A Coverage Requestor MAY query any combination or subset of the parameters. The target is formatted as:

GET [base]/CoverageEligibilityResponse?[parameter=value]

Where [base] is the URL of Claims Manager.

A Claims Manager SHALL support responding to a request for both the JSON and the XML messaging formats as defined in FHIR. A Claims Requestor SHALL accept either the JSON or the XML messaging formats as defined in FHIR. See ITI TF-2: Appendix Z.6 for more details.

A Claims Manager SHALL implement the parameters described below. A Claims Manager MAY choose to support additional query parameters beyond the subset listed below. Any additional query parameters supported SHALL be supported according to the core FHIR specification.

See ITI TF-2: Appendix W for informative implementation material for this transaction.

2:3.125.4.1.2.1 Query Parameters

The Claims Manager will support the search parameters as defined in the capability statement for CoverageEligibilityResponse.

The Coverage Requestor will support the search parameters as defined in the capability statement for CoverageEligibilityResponse.

2:3.125.4.1.3 Expected Actions

The Claims Manager SHALL process the query to retrieve the coverage eligibility response(s) that match the search parameters given, and if successful, with an HTTP 200 (OK) and a Search Coverage Eligibility Response Response Message or an error as per http://hl7.org/fhir/R4/search.html#errors.

2:3.125.4.2 Search Coverage Eligibility Response Response Message

2:3.125.4.2.1 Trigger Events

The Claims Manager found Coverage Eligibility Responses matching the query parameters specified by the Coverage Requestor as a result of a Search Coverage Eligibility Response Request.

2:3.125.4.2.2 Message Semantics

The Claims Manager SHALL support the search response message as defined at http://hl7.org/fhir/R4/http.html#search on the CoverageEligibilityResponse, as defined at http://hl7.org/fhir/R4/coverageeligibilityresponse.html.

The “content-type” of the response will depend upon the requested response format indicated by the Coverage Requestor.

See ITI TF-2: Appendix Z.6 for more details on response format handling. See ITI TF-2: Appendix Z.7 for handling guidance for Access Denied.

2:3.125.4.2.2.1 FHIR CoverageEligibilityResponse Resource Constraints

A CoverageEligibilityResponse Resource returned by the Claims Manager SHALL be further constrained as described in the FAIS CoverageEligibilityResponse profile.

2:3.125.4.2.3 Expected Actions

The Coverage Requestor has received the response and continues with its workflow.

2:3.125.4.3 Read Coverage Eligibility Response Request Message

This message represents an HTTP GET from the Coverage Requestor to the Claims Manager and provides a mechanism for retrieving a single CoverageEligibilityResponse with a known resource id.

2:3.125.4.3.1 Trigger Events

When the Coverage Requestor possesses the id of CoverageEligibilityResponse (either through query, database lookup, or other mechanism) for which it requires additional or new information, it issues a Read Coverage Eligibility Response Request.

2:3.125.4.3.2 Message Semantics

A Coverage Requestor initiates a read interaction using HTTP GET as defined at http://hl7.org/fhir/R4/http.html#read on the CoverageEligibilityResponse Resource. The target is formatted as:

GET [base]/CoverageEligibilityResponse/[resourceId]

Where [base] is the URL of Claims Manager.

The resourceId included in the request always represents the unique id for the CoverageEligibilityResponse within the scope of the URL. For example, while http://example1.org/ihe/CoverageEligibilityResponse/1 and http://example2.com/ihe/CoverageEligibilityResponse/1 both contain the same [resourceId], they reference two different resource instances.

Note: The use of “http” or “https” in URL does not override requirements to use TLS for security purposes.

A Claims Manager SHALL support responding to a request for both the JSON and the XML messaging formats as defined in FHIR. A Claims Requestor SHALL accept either the JSON or the XML messaging formats as defined in FHIR. See ITI TF-2: Appendix Z.6 for more details.

See ITI TF-2: Appendix W for informative implementation material for this transaction.

2:3.125.4.3.3 Expected Actions

The Claims Manager SHALL process the request to retrieve the CoverageEligibilityResponse that matches the given resource id, and if successful, with an HTTP 200 (OK) and a response as defined at http://hl7.org/fhir/R4/http.html#read with the Read Coverage Eligibility Response Response Message or an error code as defined at http://hl7.org/fhir/R4/http.html#Status-Codes.

2:3.125.4.4 Read Coverage Eligibility Response Response Message

2:3.125.4.4.1 Trigger Events

The Claims Manager found a CoverageEligibilityResponse Resource matching the resource identifier specified by the Coverage Requestor.

2:3.125.4.4.2 Message Semantics

The Read Coverage Eligibility Response Response is sent from the Claims Manager to the Coverage Requestor as a single CoverageEligibilityResponse, as defined at http://hl7.org/fhir/R4/coverageeligibilityresponse.html and constrained by the FAIS CoverageEligibilityResponse profile.

The “content-type” of the response will depend upon the requested response format indicated by the Coverage Requestor.

See ITI TF-2: Appendix Z.6 for more details on response format handling. See ITI TF-2: Appendix Z.7 for handling guidance for Access Denied.

If the Claims Manager is unable to produce a response in the requested format, it SHALL respond with an HTTP 4xx error indicating that it was unable to fulfill the request. The Claims Manager MAY be capable of servicing requests for response formats not listed, but SHALL, at minimum, be capable of producing XML and JSON encodings.

2:3.125.4.4.3 Expected Actions

The Coverage Requestor has received the response and continues with its workflow.

2:3.122.5 CapabilityStatement Resource

Server implementing this transaction SHALL provide a CapabilityStatement Resource as described in ITI TF-2: Appendix Z.3 indicating the transaction has been implemented.

2:3.125.6 Security Considerations

See FAIS Security Considerations.

2:3.125.6.1 Security Audit Considerations

Note that the same audit message is recorded by both the Coverage Requestor and Claims Manager. The difference being the Audit Source element. Both sides record to show consistency between the message sent by the Coverage Requestor and the action taken at the Claims Manager.

The actors performing the Check Coverage Eligibility Status Query message SHALL record audit events according to the Audit Event for Check Coverage Eligibility Status Query Transaction. See Audit Example for Check Coverage Eligibility Status search from the Claims Manager.

The actors performing the Check Coverage Eligibility Status Read message SHALL record audit events according to the Audit Event for Check Coverage Eligibility Status Read Transaction. See Audit Example for Check Coverage Eligibility Status read message from the Coverage Requestor.