Finance and Insurance Service (FAIS)
1.0.1-current - ci-build International flag

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

Resource Profile: FAIS CoverageEligibilityResponse Profile

Official URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/IHE.FAIS.CoverageEligibilityResponse Version: 1.0.1-current
Active as of 2024-11-22 Computable Name: FAISCoverageEligibilityResponse

The FAIS CoverageEligibilityResponse profile to be used as the response to the FAIS CoverageEligibilityRequest $submit

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.


... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... created Σ 1..1 dateTime Response creation date
... request Σ 1..1 Reference(FAIS CoverageEligibilityRequest Profile) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... insurer Σ 1..1 Reference(Organization) Coverage issuer

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
CoverageEligibilityResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... identifier 0..* Identifier Business Identifier for coverage eligiblity request
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.


... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... serviced[x] 0..1 Estimated date or dates of service
.... servicedDate date
.... servicedPeriod Period
... created Σ 1..1 dateTime Response creation date
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request Σ 1..1 Reference(FAIS CoverageEligibilityRequest Profile) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... disposition 0..1 string Disposition Message
... insurer Σ 1..1 Reference(Organization) Coverage issuer
... insurance 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... inforce 0..1 boolean Coverage inforce indicator
.... benefitPeriod 0..1 Period When the benefits are applicable
.... item C 0..* BackboneElement Benefits and authorization details
ces-1: SHALL contain a category or a billcode but not both.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.

..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Excluded from the plan
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

..... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

..... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

..... benefit 0..* BackboneElement Benefit Summary
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

...... allowed[x] 0..1 Benefits allowed
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
...... used[x] 0..1 Benefits used
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
CoverageEligibilityResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
CoverageEligibilityResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupportingexampleCoverageEligibilityResponseAuthSupportCodes
http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support
from the FHIR Standard
CoverageEligibilityResponse.formexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
CoverageEligibilityResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

This structure is derived from CoverageEligibilityResponse

Summary

Prohibited: 2 elements

Structures

This structure refers to these other structures:

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.


... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... created Σ 1..1 dateTime Response creation date
... request Σ 1..1 Reference(FAIS CoverageEligibilityRequest Profile) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... insurer Σ 1..1 Reference(Organization) Coverage issuer

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
CoverageEligibilityResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... identifier 0..* Identifier Business Identifier for coverage eligiblity request
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... purpose Σ 1..* code auth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.


... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... serviced[x] 0..1 Estimated date or dates of service
.... servicedDate date
.... servicedPeriod Period
... created Σ 1..1 dateTime Response creation date
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request Σ 1..1 Reference(FAIS CoverageEligibilityRequest Profile) Eligibility request reference
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... disposition 0..1 string Disposition Message
... insurer Σ 1..1 Reference(Organization) Coverage issuer
... insurance 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... inforce 0..1 boolean Coverage inforce indicator
.... benefitPeriod 0..1 Period When the benefits are applicable
.... item C 0..* BackboneElement Benefits and authorization details
ces-1: SHALL contain a category or a billcode but not both.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.

..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Excluded from the plan
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

..... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

..... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

..... benefit 0..* BackboneElement Benefit Summary
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

...... allowed[x] 0..1 Benefits allowed
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
...... used[x] 0..1 Benefits used
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
CoverageEligibilityResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
CoverageEligibilityResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupportingexampleCoverageEligibilityResponseAuthSupportCodes
http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support
from the FHIR Standard
CoverageEligibilityResponse.formexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
CoverageEligibilityResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

This structure is derived from CoverageEligibilityResponse

Summary

Prohibited: 2 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron