Finance and Insurance Service (FAIS)
1.0.0-current - ci-build
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 1.0.0-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
Active as of 2024-10-24 |
Definitions for the IHE.FAIS.CoverageEligibilityRequest resource profile.
Guidance on how to interpret the contents of this table can be found here
0. CoverageEligibilityRequest | |
2. CoverageEligibilityRequest.implicitRules | |
Control | 0..0 |
4. CoverageEligibilityRequest.extension | |
Slicing | This element introduces a set of slices on CoverageEligibilityRequest.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
6. CoverageEligibilityRequest.extension:statusReason | |
Slice Name | statusReason |
Control | 0..1 |
Type | Extension(Request Status Reason) (Extension Type: CodeableConcept) |
8. CoverageEligibilityRequest.modifierExtension | |
Control | 0..0 |
Guidance on how to interpret the contents of this table can be found here
0. CoverageEligibilityRequest | |
Definition | 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. |
Short | CoverageEligibilityRequest resource |
Control | 0..* |
Is Modifier | false |
Summary | false |
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) |
2. CoverageEligibilityRequest.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Short | A set of rules under which this content was created |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Control | 0..01 |
Type | uri |
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. CoverageEligibilityRequest.extension | |
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Short | ExtensionAdditional content defined by implementations |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on CoverageEligibilityRequest.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
6. CoverageEligibilityRequest.extension:statusReason | |
Slice Name | statusReason |
Definition | Captures the reason for the current state of the resource. |
Short | Request Status Reason |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Type | Extension(Request Status Reason) (Extension Type: CodeableConcept) |
Is Modifier | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
8. CoverageEligibilityRequest.modifierExtension | |
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | ExtensionExtensions that cannot be ignored |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..0* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Summary | false |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
10. CoverageEligibilityRequest.status | |
Definition | The status of the resource instance. |
Short | active | cancelled | draft | entered-in-error |
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
Control | 1..1 |
Binding | The codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1 )A code specifying the state of the resource instance. |
Type | code |
Is Modifier | true because 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 |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
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'. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
12. CoverageEligibilityRequest.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 | auth-requirements | benefits | discovery | validation |
Control | 1..* |
Binding | The codes SHALL be taken from EligibilityRequestPurposehttp://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 (required to http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 )A code specifying the types of information being requested. |
Type | code |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | To indicate the processing actions requested. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
14. CoverageEligibilityRequest.patient | |
Definition | The party who is the beneficiary of the supplied coverage and for whom eligibility is sought. |
Short | Intended recipient of products and services |
Comments | 1..1. |
Control | 1..1 |
Type | Reference(Patient) |
Is Modifier | false |
Summary | true |
Requirements | Required to provide context and coverage validation. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
16. CoverageEligibilityRequest.created | |
Definition | The date when this resource was created. |
Short | Creation date |
Control | 1..1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | Need to record a timestamp for use by both the recipient and the issuer. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
18. CoverageEligibilityRequest.insurer | |
Definition | The Insurer who issued the coverage in question and is the recipient of the request. |
Short | Coverage issuer |
Control | 1..1 |
Type | Reference(Organization) |
Is Modifier | false |
Summary | true |
Requirements | Need to identify the recipient. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here
0. CoverageEligibilityRequest | |||||
Definition | 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. | ||||
Short | CoverageEligibilityRequest resource | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource ( contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() )dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated ( contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() )dom-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() ) | ||||
2. CoverageEligibilityRequest.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. CoverageEligibilityRequest.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Short | Metadata about the resource | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. CoverageEligibilityRequest.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Short | A set of rules under which this content was created | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Control | 0..0 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
8. CoverageEligibilityRequest.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
10. CoverageEligibilityRequest.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Short | Text summary of the resource, for human interpretation | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. CoverageEligibilityRequest.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Short | Contained, inline Resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. CoverageEligibilityRequest.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on CoverageEligibilityRequest.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
16. CoverageEligibilityRequest.extension:statusReason | |||||
Slice Name | statusReason | ||||
Definition | Captures the reason for the current state of the resource. | ||||
Short | Request Status Reason | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Extension(Request Status Reason) (Extension Type: CodeableConcept) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
18. CoverageEligibilityRequest.modifierExtension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..0 | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
20. CoverageEligibilityRequest.identifier | |||||
Definition | A unique identifier assigned to this coverage eligiblity request. | ||||
Short | Business Identifier for coverage eligiblity request | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows coverage eligibility requests to be distinguished and referenced. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
22. CoverageEligibilityRequest.status | |||||
Definition | The status of the resource instance. | ||||
Short | active | cancelled | draft | entered-in-error | ||||
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from FinancialResourceStatusCodes (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1 )A code specifying the state of the resource instance. | ||||
Type | code | ||||
Is Modifier | true because 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 | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
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'. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
24. CoverageEligibilityRequest.priority | |||||
Definition | When the requestor expects the processor to complete processing. | ||||
Short | Desired processing priority | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcessPriorityCodes (example to http://hl7.org/fhir/ValueSet/process-priority )The timeliness with which processing is required: STAT, normal, Deferred. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to advise the prossesor on the urgency of the request. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
26. CoverageEligibilityRequest.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 | auth-requirements | benefits | discovery | validation | ||||
Control | 1..* | ||||
Binding | The codes SHALL be taken from EligibilityRequestPurpose (required to http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 )A code specifying the types of information being requested. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | To indicate the processing actions requested. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. CoverageEligibilityRequest.patient | |||||
Definition | The party who is the beneficiary of the supplied coverage and for whom eligibility is sought. | ||||
Short | Intended recipient of products and services | ||||
Comments | 1..1. | ||||
Control | 1..1 | ||||
Type | Reference(Patient) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Required to provide context and coverage validation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
30. CoverageEligibilityRequest.serviced[x] | |||||
Definition | The date or dates when the enclosed suite of services were performed or completed. | ||||
Short | Estimated date or dates of service | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Required to provide time context for the request. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
32. CoverageEligibilityRequest.created | |||||
Definition | The date when this resource was created. | ||||
Short | Creation date | ||||
Control | 1..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Need to record a timestamp for use by both the recipient and the issuer. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
34. CoverageEligibilityRequest.enterer | |||||
Definition | Person who created the request. | ||||
Short | Author | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Some jurisdictions require the contact information for personnel completing eligibility requests. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
36. CoverageEligibilityRequest.provider | |||||
Definition | The provider which is responsible for the request. | ||||
Short | Party responsible for the request | ||||
Comments | Typically this field would be 1..1 where this party is responsible for the eligibility request but not necessarily professionally responsible for the provision of the individual products and services listed below. | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner, PractitionerRole, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to identify the requestor. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
38. CoverageEligibilityRequest.insurer | |||||
Definition | The Insurer who issued the coverage in question and is the recipient of the request. | ||||
Short | Coverage issuer | ||||
Control | 1..1 | ||||
Type | Reference(Organization) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Need to identify the recipient. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
40. CoverageEligibilityRequest.facility | |||||
Definition | Facility where the services are intended to be provided. | ||||
Short | Servicing facility | ||||
Control | 0..1 | ||||
Type | Reference(Location) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Insurance adjudication can be dependant on where services were delivered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
42. CoverageEligibilityRequest.supportingInfo | |||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Supporting information | ||||
Comments | Often there are multiple jurisdiction specific valuesets which are required. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. CoverageEligibilityRequest.supportingInfo.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
46. CoverageEligibilityRequest.supportingInfo.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
48. CoverageEligibilityRequest.supportingInfo.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
50. CoverageEligibilityRequest.supportingInfo.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
52. CoverageEligibilityRequest.supportingInfo.information | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 1..1 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
54. CoverageEligibilityRequest.supportingInfo.appliesToAll | |||||
Definition | The supporting materials are applicable for all detail items, product/servce categories and specific billing codes. | ||||
Short | Applies to all items | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Needed to convey that the information is universal to the request. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
56. CoverageEligibilityRequest.insurance | |||||
Definition | Financial instruments for reimbursement for the health care products and services. | ||||
Short | Patient insurance information | ||||
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. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | There must be at least one coverage for which eligibility is requested. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
58. CoverageEligibilityRequest.insurance.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
60. CoverageEligibilityRequest.insurance.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
62. CoverageEligibilityRequest.insurance.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
64. CoverageEligibilityRequest.insurance.focal | |||||
Definition | A flag to indicate that this Coverage is to be used for evaluation of this request when set to true. | ||||
Short | Applicable coverage | ||||
Comments | A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for evaluating this request. Other requests would be created to request evaluation against the other listed policies. | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To identify which coverage in the list is being used to evaluate this request. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. CoverageEligibilityRequest.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 | Insurance information | ||||
Control | 1..1 | ||||
Type | Reference(Coverage) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
68. CoverageEligibilityRequest.insurance.businessArrangement | |||||
Definition | A business agreement number established between the provider and the insurer for special business processing purposes. | ||||
Short | Additional provider contract number | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
70. CoverageEligibilityRequest.item | |||||
Definition | Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor. | ||||
Short | Item to be evaluated for eligibiity | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The items to be processed for the request. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
72. CoverageEligibilityRequest.item.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
74. CoverageEligibilityRequest.item.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
76. CoverageEligibilityRequest.item.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
78. CoverageEligibilityRequest.item.supportingInfoSequence | |||||
Definition | Exceptions, special conditions and supporting information applicable for this service or product line. | ||||
Short | Applicable exception or supporting information | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Needed to support or inform the consideration for eligibility. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
80. CoverageEligibilityRequest.item.category | |||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short | Benefit classification | ||||
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
Control | 0..1 | ||||
Binding | For example codes, see BenefitCategoryCodes (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory )Benefit categories such as: oral, medical, vision etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to convey the category of service or product for which eligibility is sought. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
82. CoverageEligibilityRequest.item.productOrService | |||||
Definition | This contains the product, service, drug or other billing code for the item. | ||||
Short | Billing, service, product, or drug code | ||||
Comments | Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). | ||||
Control | 0..1 | ||||
Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls )Allowable service and product codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to convey the actual service or product for which eligibility is sought. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
84. CoverageEligibilityRequest.item.modifier | |||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short | Product or service billing modifiers | ||||
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. | ||||
Control | 0..* | ||||
Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers )Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support provision of the item or to charge an elevated fee. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
86. CoverageEligibilityRequest.item.provider | |||||
Definition | The practitioner who is responsible for the product or service to be rendered to the patient. | ||||
Short | Perfoming practitioner | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to support the evaluation of the eligibility. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
88. CoverageEligibilityRequest.item.quantity | |||||
Definition | The number of repetitions of a service or product. | ||||
Short | Count of products or services | ||||
Control | 0..1 | ||||
Type | Quantity(SimpleQuantity) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. CoverageEligibilityRequest.item.unitPrice | |||||
Definition | The amount charged to the patient by the provider for a single unit. | ||||
Short | Fee, charge or cost per item | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to support the evaluation of the eligibility. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
92. CoverageEligibilityRequest.item.facility | |||||
Definition | Facility where the services will be provided. | ||||
Short | Servicing facility | ||||
Control | 0..1 | ||||
Type | Reference(Location, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to support the evaluation of the eligibility. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
94. CoverageEligibilityRequest.item.diagnosis | |||||
Definition | Patient diagnosis for which care is sought. | ||||
Short | Applicable diagnosis | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to support the evaluation of the eligibility. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
96. CoverageEligibilityRequest.item.diagnosis.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
98. CoverageEligibilityRequest.item.diagnosis.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
100. CoverageEligibilityRequest.item.diagnosis.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
102. CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | |||||
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition. | ||||
Short | Nature of illness or problem | ||||
Control | 0..1 | ||||
Binding | For example codes, see ICD-10Codes (example to http://hl7.org/fhir/ValueSet/icd-10 )ICD10 Diagnostic codes. | ||||
Type | Choice of: CodeableConcept, Reference(Condition) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides health context for the evaluation of the products and/or services. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
104. CoverageEligibilityRequest.item.detail | |||||
Definition | The plan/proposal/order describing the proposed service in detail. | ||||
Short | Product or service details | ||||
Control | 0..* | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to provide complex service proposal such as a Device or a plan. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |