Release 4 5 Preview #3
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13.2 Resource CoverageEligibilityRequest - Content

Financial Management Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Patient , Practitioner

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.

The CoverageEligibilityRequest makes a request of an insurer asking them to provide, in the form of an CoverageEligibilityResponse, information regarding: (validation) whether the specified coverage(s) is valid and in-force; (discovery) what coverages the insurer has for the specified patient; (benefits) the benefits provided under the coverage; whether benefits exist under the specified coverage(s) for specified classes of services and products; and (auth-requirements) whether preauthorization is required, and if so what information may be required in that preauthorization, for the specified service classes or services.

The CoverageEligibilityRequest resource is a "event" resource from a FHIR workflow perspective - see Workflow Event.

Additional information regarding electronic coverage eligibility content and usage may be found at:

  • Financial Resource Status Lifecycle : how .status is used in the financial resources.
  • Subrogation : how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit : how eClaims may handle multiple patient insurance coverages.
  • Batches : how eClaims may handle batches of eligibility, claims and responses.
  • Attachments and Supporting Information : how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This includes how payors how request additional supporting information from providers.

CoverageEligibilityRequest should be used when requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage.

The Claim resource should be used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

The Coverage resource contains the information typically found on the health insurance card for an individual used to identify the covered individual to the insurer and is referred to by the CoverageEligibilityRequest.

The eClaim domain includes a number of related resources

CoverageEligibilityRequest Patient and insurance coverage information provided 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.
Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
Coverage Provides the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services.

This resource is referenced by CoverageEligibilityResponse .

This resource implements the Request pattern.

Structure

Name Flags Card. Type Description & Constraints doco
. . CoverageEligibilityRequest TU DomainResource CoverageEligibilityRequest resource
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier for coverage eligiblity request
. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . priority 0..1 CodeableConcept Desired processing priority
Process Priority Codes ( Example )
. . . 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 Creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author
. . . provider 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the request
. . . insurer Σ 1..1 Reference ( Organization ) Coverage issuer
. . . facility 0..1 Reference ( Location ) Servicing facility
. . . supportingInfo 0..* BackboneElement Supporting information
. . . . sequence 1..1 positiveInt Information instance identifier
. . . . information 1..1 Reference ( Any ) Data to be provided
. . . . appliesToAll 0..1 boolean Applies to all items
. . . insurance 0..* BackboneElement Patient insurance information
. . . . focal 0..1 boolean Applicable coverage
. . . . coverage 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Additional provider contract number
. . . item 0..* BackboneElement Item to be evaluated for eligibiity
. . . . supportingInfoSequence 0..* positiveInt Applicable exception or supporting information
. . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example )
. . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . modifier 0..* CodeableConcept Product or service billing modifiers
Modifier type Codes ( Example )
. . . . provider 0..1 Reference ( Practitioner | PractitionerRole ) Perfoming practitioner
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . facility 0..1 Reference ( Location | Organization ) Servicing facility
. . . . diagnosis 0..* BackboneElement Applicable diagnosis
. . . . . diagnosis[x] 0..1 Nature of illness or problem
ICD-10 Codes ( Example )
. . . . . . diagnosisCodeableConcept CodeableConcept
. . . . . . diagnosisReference Reference ( Condition )
. . . . detail 0..* Reference ( Any ) Product or service details

doco Documentation for this format

UML Diagram ( Legend )

CoverageEligibilityRequest ( DomainResource ) A unique identifier assigned to this coverage eligiblity request identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required) FinancialResourceStatusCodes ! » When the requestor expects the processor to complete processing priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example) ProcessPriorityCodes ?? » 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 purpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required) EligibilityRequestPurpose ! » The party who is the beneficiary of the supplied coverage and for whom eligibility is sought patient : Reference [1..1] « Patient » The date or dates when the enclosed suite of services were performed or completed serviced[x] : Type DataType [0..1] « date | Period » The date when this resource was created created : dateTime [1..1] Person who created the request enterer : Reference [0..1] « Practitioner | PractitionerRole » The provider which is responsible for the request provider : Reference [0..1] « Practitioner | PractitionerRole | Organization » The Insurer who issued the coverage in question and is the recipient of the request insurer : Reference [1..1] « Organization » Facility where the services are intended to be provided facility : Reference [0..1] « Location » SupportingInformation A number to uniquely identify supporting information entries sequence : positiveInt [1..1] Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data information : Reference [1..1] « Any » The supporting materials are applicable for all detail items, product/servce categories and specific billing codes appliesToAll : boolean [0..1] Insurance A flag to indicate that this Coverage is to be used for evaluation of this request when set to true focal : boolean [0..1] 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 coverage : Reference [1..1] « Coverage » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] Details Exceptions, special conditions and supporting information applicable for this service or product line supportingInfoSequence : positiveInt [0..*] Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) BenefitCategoryCodes ?? » This contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) ModifierTypeCodes ?? » The practitioner who is responsible for the product or service to be rendered to the patient provider : Reference [0..1] « Practitioner | PractitionerRole » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The amount charged to the patient by the provider for a single unit unitPrice : Money [0..1] Facility where the services will be provided facility : Reference [0..1] « Location | Organization » The plan/proposal/order describing the proposed service in detail detail : Reference [0..*] « Any » Diagnosis The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type DataType [0..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes ?? » Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Financial instruments for reimbursement for the health care products and services insurance [0..*] Patient diagnosis for which care is sought diagnosis [0..*] Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor item [0..*]

XML Template

<CoverageEligibilityRequest xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation -->
 <patient><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]>
 <created value="[dateTime]"/><!-- 1..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <</provider>

 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></provider>

 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing facility --></facility>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <information><!-- 1..1 Reference(Any) Data to be provided --></information>
  <appliesToAll value="[boolean]"/><!-- 0..1 Applies to all items -->
 </supportingInfo>
 <insurance>  <!-- 0..* Patient insurance information -->
  <focal value="[boolean]"/><!-- 0..1 Applicable coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
 </insurance>
 <item>  <!-- 0..* Item to be evaluated for eligibiity -->
  <supportingInfoSequence value="[positiveInt]"/><!-- 0..* Applicable exception or supporting information -->
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Perfoming practitioner --></provider>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility>
  <diagnosis>  <!-- 0..* Applicable diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  </diagnosis>
  <detail><!-- 0..* Reference(Any) Product or service details --></detail>
 </item>
</CoverageEligibilityRequest>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityRequest",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "priority" : { CodeableConcept }, // Desired processing priority
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "patient" : { Reference(Patient) }, // R!  Intended recipient of products and services
  // serviced[x]: Estimated date or dates of service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // R!  Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "

  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request

  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "facility" : { Reference(Location) }, // Servicing facility
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "information" : { Reference(Any) }, // R!  Data to be provided
    "appliesToAll" : <boolean> // Applies to all items
  }],
  "insurance" : [{ // Patient insurance information
    "focal" : <boolean>, // Applicable coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>" // Additional provider contract number
  }],
  "item" : [{ // Item to be evaluated for eligibiity
    "supportingInfoSequence" : ["<positiveInt>"], // Applicable exception or supporting information
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "provider" : { Reference(Practitioner|PractitionerRole) }, // Perfoming practitioner
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "facility" : { Reference(Location|Organization) }, // Servicing facility
    "diagnosis" : [{ // Applicable diagnosis
      // diagnosis[x]: Nature of illness or problem. One of these 2:
      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }],
    "detail" : [{ Reference(Any) }] // Product or service details
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:CoverageEligibilityRequest;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CoverageEligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityRequest.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:CoverageEligibilityRequest.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityRequest.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityRequest.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityRequest.servicedDate [ date ]
    fhir:CoverageEligibilityRequest.servicedPeriod [ Period ]
  fhir:CoverageEligibilityRequest.created [ dateTime ]; # 1..1 Creation date
  fhir:CoverageEligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:

  fhir:CoverageEligibilityRequest.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the request

  fhir:CoverageEligibilityRequest.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing facility
  fhir:CoverageEligibilityRequest.supportingInfo [ # 0..* Supporting information
    fhir:CoverageEligibilityRequest.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:CoverageEligibilityRequest.supportingInfo.information [ Reference(Any) ]; # 1..1 Data to be provided
    fhir:CoverageEligibilityRequest.supportingInfo.appliesToAll [ boolean ]; # 0..1 Applies to all items
  ], ...;
  fhir:CoverageEligibilityRequest.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityRequest.insurance.focal [ boolean ]; # 0..1 Applicable coverage
    fhir:CoverageEligibilityRequest.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityRequest.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
  ], ...;
  fhir:CoverageEligibilityRequest.item [ # 0..* Item to be evaluated for eligibiity
    fhir:CoverageEligibilityRequest.item.supportingInfoSequence [ positiveInt ], ... ; # 0..* Applicable exception or supporting information
    fhir:CoverageEligibilityRequest.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:CoverageEligibilityRequest.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
    fhir:CoverageEligibilityRequest.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:CoverageEligibilityRequest.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Perfoming practitioner
    fhir:CoverageEligibilityRequest.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:CoverageEligibilityRequest.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:CoverageEligibilityRequest.item.facility [ Reference(Location|Organization) ]; # 0..1 Servicing facility
    fhir:CoverageEligibilityRequest.item.diagnosis [ # 0..* Applicable diagnosis
      # CoverageEligibilityRequest.item.diagnosis.diagnosis[x] : 0..1 Nature of illness or problem. One of these 2
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
    fhir:CoverageEligibilityRequest.item.detail [ Reference(Any) ], ... ; # 0..* Product or service details
  ], ...;
]

Changes since R3

CoverageEligibilityRequest
CoverageEligibilityRequest.status
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.5.0
CoverageEligibilityRequest.purpose
  • Change value set from http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.0 to http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.5.0

This resource did not exist in Release 2 See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = Not Mapped)

Structure

Name Flags Card. Type Description & Constraints doco
. . CoverageEligibilityRequest TU DomainResource CoverageEligibilityRequest resource
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier for coverage eligiblity request
. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . priority 0..1 CodeableConcept Desired processing priority
Process Priority Codes ( Example )
. . . 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 Creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author
. . . provider 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the request
. . . insurer Σ 1..1 Reference ( Organization ) Coverage issuer
. . . facility 0..1 Reference ( Location ) Servicing facility
. . . supportingInfo 0..* BackboneElement Supporting information
. . . . sequence 1..1 positiveInt Information instance identifier
. . . . information 1..1 Reference ( Any ) Data to be provided
. . . . appliesToAll 0..1 boolean Applies to all items
. . . insurance 0..* BackboneElement Patient insurance information
. . . . focal 0..1 boolean Applicable coverage
. . . . coverage 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Additional provider contract number
. . . item 0..* BackboneElement Item to be evaluated for eligibiity
. . . . supportingInfoSequence 0..* positiveInt Applicable exception or supporting information
. . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example )
. . . . productOrService 0..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . modifier 0..* CodeableConcept Product or service billing modifiers
Modifier type Codes ( Example )
. . . . provider 0..1 Reference ( Practitioner | PractitionerRole ) Perfoming practitioner
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . facility 0..1 Reference ( Location | Organization ) Servicing facility
. . . . diagnosis 0..* BackboneElement Applicable diagnosis
. . . . . diagnosis[x] 0..1 Nature of illness or problem
ICD-10 Codes ( Example )
. . . . . . diagnosisCodeableConcept CodeableConcept
. . . . . . diagnosisReference Reference ( Condition )
. . . . detail 0..* Reference ( Any ) Product or service details

doco Documentation for this format

UML Diagram ( Legend )

CoverageEligibilityRequest ( DomainResource ) A unique identifier assigned to this coverage eligiblity request identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required) FinancialResourceStatusCodes ! » When the requestor expects the processor to complete processing priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example) ProcessPriorityCodes ?? » 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 purpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required) EligibilityRequestPurpose ! » The party who is the beneficiary of the supplied coverage and for whom eligibility is sought patient : Reference [1..1] « Patient » The date or dates when the enclosed suite of services were performed or completed serviced[x] : Type DataType [0..1] « date | Period » The date when this resource was created created : dateTime [1..1] Person who created the request enterer : Reference [0..1] « Practitioner | PractitionerRole » The provider which is responsible for the request provider : Reference [0..1] « Practitioner | PractitionerRole | Organization » The Insurer who issued the coverage in question and is the recipient of the request insurer : Reference [1..1] « Organization » Facility where the services are intended to be provided facility : Reference [0..1] « Location » SupportingInformation A number to uniquely identify supporting information entries sequence : positiveInt [1..1] Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data information : Reference [1..1] « Any » The supporting materials are applicable for all detail items, product/servce categories and specific billing codes appliesToAll : boolean [0..1] Insurance A flag to indicate that this Coverage is to be used for evaluation of this request when set to true focal : boolean [0..1] 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 coverage : Reference [1..1] « Coverage » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] Details Exceptions, special conditions and supporting information applicable for this service or product line supportingInfoSequence : positiveInt [0..*] Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) BenefitCategoryCodes ?? » This contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) ModifierTypeCodes ?? » The practitioner who is responsible for the product or service to be rendered to the patient provider : Reference [0..1] « Practitioner | PractitionerRole » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The amount charged to the patient by the provider for a single unit unitPrice : Money [0..1] Facility where the services will be provided facility : Reference [0..1] « Location | Organization » The plan/proposal/order describing the proposed service in detail detail : Reference [0..*] « Any » Diagnosis The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type DataType [0..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes ?? » Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Financial instruments for reimbursement for the health care products and services insurance [0..*] Patient diagnosis for which care is sought diagnosis [0..*] Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor item [0..*]

XML Template

<CoverageEligibilityRequest xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation -->
 <patient><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]>
 <created value="[dateTime]"/><!-- 1..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <</provider>

 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the request --></provider>

 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing facility --></facility>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <information><!-- 1..1 Reference(Any) Data to be provided --></information>
  <appliesToAll value="[boolean]"/><!-- 0..1 Applies to all items -->
 </supportingInfo>
 <insurance>  <!-- 0..* Patient insurance information -->
  <focal value="[boolean]"/><!-- 0..1 Applicable coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
 </insurance>
 <item>  <!-- 0..* Item to be evaluated for eligibiity -->
  <supportingInfoSequence value="[positiveInt]"/><!-- 0..* Applicable exception or supporting information -->
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Perfoming practitioner --></provider>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility>
  <diagnosis>  <!-- 0..* Applicable diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  </diagnosis>
  <detail><!-- 0..* Reference(Any) Product or service details --></detail>
 </item>
</CoverageEligibilityRequest>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityRequest",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "priority" : { CodeableConcept }, // Desired processing priority
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "patient" : { Reference(Patient) }, // R!  Intended recipient of products and services
  // serviced[x]: Estimated date or dates of service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // R!  Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "

  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the request

  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "facility" : { Reference(Location) }, // Servicing facility
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "information" : { Reference(Any) }, // R!  Data to be provided
    "appliesToAll" : <boolean> // Applies to all items
  }],
  "insurance" : [{ // Patient insurance information
    "focal" : <boolean>, // Applicable coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>" // Additional provider contract number
  }],
  "item" : [{ // Item to be evaluated for eligibiity
    "supportingInfoSequence" : ["<positiveInt>"], // Applicable exception or supporting information
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "provider" : { Reference(Practitioner|PractitionerRole) }, // Perfoming practitioner
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "facility" : { Reference(Location|Organization) }, // Servicing facility
    "diagnosis" : [{ // Applicable diagnosis
      // diagnosis[x]: Nature of illness or problem. One of these 2:
      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }],
    "detail" : [{ Reference(Any) }] // Product or service details
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:CoverageEligibilityRequest;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CoverageEligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityRequest.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:CoverageEligibilityRequest.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityRequest.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityRequest.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityRequest.servicedDate [ date ]
    fhir:CoverageEligibilityRequest.servicedPeriod [ Period ]
  fhir:CoverageEligibilityRequest.created [ dateTime ]; # 1..1 Creation date
  fhir:CoverageEligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:

  fhir:CoverageEligibilityRequest.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the request

  fhir:CoverageEligibilityRequest.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing facility
  fhir:CoverageEligibilityRequest.supportingInfo [ # 0..* Supporting information
    fhir:CoverageEligibilityRequest.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:CoverageEligibilityRequest.supportingInfo.information [ Reference(Any) ]; # 1..1 Data to be provided
    fhir:CoverageEligibilityRequest.supportingInfo.appliesToAll [ boolean ]; # 0..1 Applies to all items
  ], ...;
  fhir:CoverageEligibilityRequest.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityRequest.insurance.focal [ boolean ]; # 0..1 Applicable coverage
    fhir:CoverageEligibilityRequest.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityRequest.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
  ], ...;
  fhir:CoverageEligibilityRequest.item [ # 0..* Item to be evaluated for eligibiity
    fhir:CoverageEligibilityRequest.item.supportingInfoSequence [ positiveInt ], ... ; # 0..* Applicable exception or supporting information
    fhir:CoverageEligibilityRequest.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:CoverageEligibilityRequest.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
    fhir:CoverageEligibilityRequest.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:CoverageEligibilityRequest.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Perfoming practitioner
    fhir:CoverageEligibilityRequest.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:CoverageEligibilityRequest.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:CoverageEligibilityRequest.item.facility [ Reference(Location|Organization) ]; # 0..1 Servicing facility
    fhir:CoverageEligibilityRequest.item.diagnosis [ # 0..* Applicable diagnosis
      # CoverageEligibilityRequest.item.diagnosis.diagnosis[x] : 0..1 Nature of illness or problem. One of these 2
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:CoverageEligibilityRequest.item.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
    fhir:CoverageEligibilityRequest.item.detail [ Reference(Any) ], ... ; # 0..* Product or service details
  ], ...;
]

Changes since Release 3

CoverageEligibilityRequest
CoverageEligibilityRequest.status
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.5.0
CoverageEligibilityRequest.purpose
  • Change value set from http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.0 to http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.5.0

This resource did not exist in Release 2 See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = Not Mapped)

 

See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis a

Path Definition Type Reference
CoverageEligibilityRequest.status A code specifying the state of the resource instance. Required FinancialResourceStatusCodes
CoverageEligibilityRequest.priority The timeliness with which processing is required: STAT, normal, Deferred. Example ProcessPriorityCodes
CoverageEligibilityRequest.purpose A code specifying the types of information being requested. Required EligibilityRequestPurpose
CoverageEligibilityRequest.item.category Benefit categories such as: oral, medical, vision etc. Example BenefitCategoryCodes
CoverageEligibilityRequest.item.productOrService Allowable service and product codes. Example USCLSCodes
CoverageEligibilityRequest.item.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. Example ModifierTypeCodes
CoverageEligibilityRequest.item.diagnosis.diagnosis[x] ICD10 Diagnostic codes. Example ICD-10Codes

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
created N date The creation date for the EOB CoverageEligibilityRequest.created
enterer reference The party who is responsible for the request CoverageEligibilityRequest.enterer
( Practitioner , PractitionerRole )
facility reference Facility responsible for the goods and services CoverageEligibilityRequest.facility
( Location )
identifier token The business identifier of the Eligibility CoverageEligibilityRequest.identifier
patient reference The reference to the patient CoverageEligibilityRequest.patient
( Patient )
provider reference The reference to the provider CoverageEligibilityRequest.provider
( Practitioner , Organization , PractitionerRole )
status N token The status of the EligibilityRequest CoverageEligibilityRequest.status