DHIN 2025Connectathon FHIR IG
0.2.0 - ci-build
DHIN 2025Connectathon FHIR IG, published by DHIN. This guide is not an authorized publication; it is the continuous build for version 0.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Nigeria-FHIR-Community/2025Connectathon/ and changes regularly. See the Directory of published versions
| Official URL: https://sandbox.dhin-hie.org/ig/StructureDefinition/ng-coverage-eligibility-response | Version: 0.2.0 | |||
| Draft as of 2025-11-19 | Computable Name: NgCoverageEligibilityResponse | |||
Profile defining the response from an HMO to an eligibilty request
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
S | 0..* | Identifier | Business Identifier for coverage eligiblity request |
![]() ![]() |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) |
![]() ![]() |
SΣ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required) |
![]() ![]() |
SΣ | 1..1 | Reference(NG Patient) | Intended recipient of products and services |
![]() ![]() |
SΣ | 1..1 | dateTime | Response creation date |
![]() ![]() |
0..1 | Reference(NG Provider Organization) | Party responsible for the request | |
![]() ![]() |
SΣ | 1..1 | Reference(NG Claim Coverage Eligibility Request) | Eligibility request reference |
![]() ![]() |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
![]() ![]() |
SΣ | 1..1 | Reference(NG Insurer Organization) | Coverage issuer |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| CoverageEligibilityResponse.status | Base | required | Financial Resource Status Codes | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.purpose | Base | required | EligibilityResponsePurpose | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.outcome | Base | required | Claim Processing Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | CoverageEligibilityResponse | 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 | error | CoverageEligibilityResponse | 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 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | CoverageEligibilityResponse | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from CoverageEligibilityResponse
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |
![]() ![]() |
S | 0..* | Identifier | Business Identifier for coverage eligiblity request |
![]() ![]() |
S | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) |
![]() ![]() |
S | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required) |
![]() ![]() |
S | 1..1 | Reference(NG Patient) | Intended recipient of products and services |
![]() ![]() |
S | 1..1 | dateTime | Response creation date |
![]() ![]() |
0..1 | Reference(NG Provider Organization) | Party responsible for the request | |
![]() ![]() |
S | 1..1 | Reference(NG Claim Coverage Eligibility Request) | Eligibility request reference |
![]() ![]() |
S | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
![]() ![]() |
S | 1..1 | Reference(NG Insurer Organization) | Coverage issuer |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| CoverageEligibilityResponse.status | Base | required | Financial Resource Status Codes | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.purpose | Base | required | EligibilityResponsePurpose | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.outcome | Base | required | Claim Processing Codes | 📦4.0.1 | FHIR Std. |
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() |
S | 0..* | Identifier | Business Identifier for coverage eligiblity request | ||||
![]() ![]() |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) | ||||
![]() ![]() |
SΣ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required) | ||||
![]() ![]() |
SΣ | 1..1 | Reference(NG Patient) | Intended recipient of products and services | ||||
![]() ![]() |
0..1 | Estimated date or dates of service | ||||||
![]() ![]() ![]() |
date | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() |
SΣ | 1..1 | dateTime | Response creation date | ||||
![]() ![]() |
0..1 | Reference(NG Provider Organization) | Party responsible for the request | |||||
![]() ![]() |
SΣ | 1..1 | Reference(NG Claim Coverage Eligibility Request) | Eligibility request reference | ||||
![]() ![]() |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) | ||||
![]() ![]() |
0..1 | string | Disposition Message | |||||
![]() ![]() |
SΣ | 1..1 | Reference(NG Insurer Organization) | Coverage issuer | ||||
![]() ![]() |
0..* | BackboneElement | Patient insurance information | |||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
![]() ![]() ![]() |
0..1 | boolean | Coverage inforce indicator | |||||
![]() ![]() ![]() |
0..1 | Period | When the benefits are applicable | |||||
![]() ![]() ![]() |
C | 0..* | BackboneElement | Benefits and authorization details Constraints: ces-1 | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() |
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. | |||||
![]() ![]() ![]() ![]() |
0..1 | Reference(Practitioner | PractitionerRole) | Performing practitioner | |||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Excluded from the plan | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Short name for the benefit | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Description of the benefit or services covered | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
![]() ![]() ![]() ![]() |
0..* | BackboneElement | Benefit Summary | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Benefits allowed | ||||||
![]() ![]() ![]() ![]() ![]() ![]() |
unsignedInt | |||||||
![]() ![]() ![]() ![]() ![]() ![]() |
string | |||||||
![]() ![]() ![]() ![]() ![]() ![]() |
Money | |||||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Benefits used | ||||||
![]() ![]() ![]() ![]() ![]() ![]() |
unsignedInt | |||||||
![]() ![]() ![]() ![]() ![]() ![]() |
string | |||||||
![]() ![]() ![]() ![]() ![]() ![]() |
Money | |||||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Authorization required flag | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization. | |||||
![]() ![]() ![]() ![]() |
0..1 | uri | Preauthorization requirements endpoint | |||||
![]() ![]() |
0..1 | string | Preauthorization reference | |||||
![]() ![]() |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
![]() ![]() |
0..* | BackboneElement | Processing errors | |||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing. | |||||
Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| CoverageEligibilityResponse.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.status | Base | required | Financial Resource Status Codes | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.purpose | Base | required | EligibilityResponsePurpose | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.outcome | Base | required | Claim Processing Codes | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.unit | Base | example | Unit Type Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.term | Base | example | Benefit Term Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.benefit.type | Base | example | Benefit Type Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.authorizationSupporting | Base | example | CoverageEligibilityResponse Auth Support Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.form | Base | example | Forms | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.error.code | Base | example | AdjudicationError | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| ces-1 | error | CoverageEligibilityResponse.insurance.item | SHALL contain a category or a billcode but not both. |
category.exists() xor productOrService.exists()
|
| dom-2 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | CoverageEligibilityResponse | 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 | error | CoverageEligibilityResponse | 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 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | CoverageEligibilityResponse | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from CoverageEligibilityResponse
Summary
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
S | 0..* | Identifier | Business Identifier for coverage eligiblity request |
![]() ![]() |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) |
![]() ![]() |
SΣ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required) |
![]() ![]() |
SΣ | 1..1 | Reference(NG Patient) | Intended recipient of products and services |
![]() ![]() |
SΣ | 1..1 | dateTime | Response creation date |
![]() ![]() |
0..1 | Reference(NG Provider Organization) | Party responsible for the request | |
![]() ![]() |
SΣ | 1..1 | Reference(NG Claim Coverage Eligibility Request) | Eligibility request reference |
![]() ![]() |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
![]() ![]() |
SΣ | 1..1 | Reference(NG Insurer Organization) | Coverage issuer |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| CoverageEligibilityResponse.status | Base | required | Financial Resource Status Codes | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.purpose | Base | required | EligibilityResponsePurpose | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.outcome | Base | required | Claim Processing Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | CoverageEligibilityResponse | 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 | error | CoverageEligibilityResponse | 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 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | CoverageEligibilityResponse | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
Differential View
This structure is derived from CoverageEligibilityResponse
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |
![]() ![]() |
S | 0..* | Identifier | Business Identifier for coverage eligiblity request |
![]() ![]() |
S | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) |
![]() ![]() |
S | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required) |
![]() ![]() |
S | 1..1 | Reference(NG Patient) | Intended recipient of products and services |
![]() ![]() |
S | 1..1 | dateTime | Response creation date |
![]() ![]() |
0..1 | Reference(NG Provider Organization) | Party responsible for the request | |
![]() ![]() |
S | 1..1 | Reference(NG Claim Coverage Eligibility Request) | Eligibility request reference |
![]() ![]() |
S | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
![]() ![]() |
S | 1..1 | Reference(NG Insurer Organization) | Coverage issuer |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| CoverageEligibilityResponse.status | Base | required | Financial Resource Status Codes | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.purpose | Base | required | EligibilityResponsePurpose | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.outcome | Base | required | Claim Processing Codes | 📦4.0.1 | FHIR Std. |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() |
S | 0..* | Identifier | Business Identifier for coverage eligiblity request | ||||
![]() ![]() |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) | ||||
![]() ![]() |
SΣ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required) | ||||
![]() ![]() |
SΣ | 1..1 | Reference(NG Patient) | Intended recipient of products and services | ||||
![]() ![]() |
0..1 | Estimated date or dates of service | ||||||
![]() ![]() ![]() |
date | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() |
SΣ | 1..1 | dateTime | Response creation date | ||||
![]() ![]() |
0..1 | Reference(NG Provider Organization) | Party responsible for the request | |||||
![]() ![]() |
SΣ | 1..1 | Reference(NG Claim Coverage Eligibility Request) | Eligibility request reference | ||||
![]() ![]() |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) | ||||
![]() ![]() |
0..1 | string | Disposition Message | |||||
![]() ![]() |
SΣ | 1..1 | Reference(NG Insurer Organization) | Coverage issuer | ||||
![]() ![]() |
0..* | BackboneElement | Patient insurance information | |||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
![]() ![]() ![]() |
0..1 | boolean | Coverage inforce indicator | |||||
![]() ![]() ![]() |
0..1 | Period | When the benefits are applicable | |||||
![]() ![]() ![]() |
C | 0..* | BackboneElement | Benefits and authorization details Constraints: ces-1 | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() |
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. | |||||
![]() ![]() ![]() ![]() |
0..1 | Reference(Practitioner | PractitionerRole) | Performing practitioner | |||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Excluded from the plan | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Short name for the benefit | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Description of the benefit or services covered | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
![]() ![]() ![]() ![]() |
0..* | BackboneElement | Benefit Summary | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Benefits allowed | ||||||
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unsignedInt | |||||||
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string | |||||||
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Money | |||||||
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0..1 | Benefits used | ||||||
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unsignedInt | |||||||
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string | |||||||
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Money | |||||||
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0..1 | boolean | Authorization required flag | |||||
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0..* | CodeableConcept | Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization. | |||||
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0..1 | uri | Preauthorization requirements endpoint | |||||
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0..1 | string | Preauthorization reference | |||||
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0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
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0..* | BackboneElement | Processing errors | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing. | |||||
Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| CoverageEligibilityResponse.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.status | Base | required | Financial Resource Status Codes | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.purpose | Base | required | EligibilityResponsePurpose | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.outcome | Base | required | Claim Processing Codes | 📦4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.unit | Base | example | Unit Type Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.term | Base | example | Benefit Term Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.benefit.type | Base | example | Benefit Type Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.insurance.item.authorizationSupporting | Base | example | CoverageEligibilityResponse Auth Support Codes | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.form | Base | example | Forms | 📍4.0.1 | FHIR Std. |
| CoverageEligibilityResponse.error.code | Base | example | AdjudicationError | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| ces-1 | error | CoverageEligibilityResponse.insurance.item | SHALL contain a category or a billcode but not both. |
category.exists() xor productOrService.exists()
|
| dom-2 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | CoverageEligibilityResponse | 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 | error | CoverageEligibilityResponse | 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 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | CoverageEligibilityResponse | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from CoverageEligibilityResponse
Summary
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron