Release 4 5 Preview #3
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Financial Management Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Patient , Practitioner

Detailed Descriptions for the elements in the CoverageEligibilityResponse resource.

CoverageEligibilityResponse
Element Id CoverageEligibilityResponse
Definition

This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.

Cardinality 0..*
Type DomainResource
CoverageEligibilityResponse.identifier
Element Id CoverageEligibilityResponse.identifier
Definition

A unique identifier assigned to this coverage eligiblity request.

Note This is a business identifier, not a resource identifier (see discussion )
Cardinality 0..*
Type Identifier
Requirements

Allows coverage eligibility requests to be distinguished and referenced.

CoverageEligibilityResponse.status
Element Id CoverageEligibilityResponse.status
Definition

The status of the resource instance.

Cardinality 1..1
Terminology Binding Financial Resource Status Codes ( Required )
Type code
Is Modifier true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Summary true
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

CoverageEligibilityResponse.purpose
Element Id CoverageEligibilityResponse.purpose
Definition

Code to specify whether requesting: prior authorization requirements for some service categories or billing codes; benefits for coverages specified or discovered; discovery and return of coverages for the patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.

Cardinality 1..*
Terminology Binding EligibilityResponsePurpose ( Required )
Type code
Requirements

To indicate the processing actions requested.

Summary true
CoverageEligibilityResponse.patient
Element Id CoverageEligibilityResponse.patient
Definition

The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.

Cardinality 1..1
Type Reference ( Patient )
Requirements

Required to provide context and coverage validation.

Summary true
CoverageEligibilityResponse.serviced[x]
Element Id CoverageEligibilityResponse.serviced[x]
Definition

The date or dates when the enclosed suite of services were performed or completed.

Cardinality 0..1
Type date | Period
[x] Note See Choice of Data Types for further information about how to use [x]
Requirements

Required to provide time context for the request.

CoverageEligibilityResponse.created
Element Id CoverageEligibilityResponse.created
Definition

The date this resource was created.

Cardinality 1..1
Type dateTime
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Summary true
CoverageEligibilityResponse.requestor
Element Id CoverageEligibilityResponse.requestor
Definition

The provider which is responsible for the request.

Cardinality 0..1
Type Reference ( Practitioner | PractitionerRole | Organization )
Patterns Reference(Practitioner,PractitionerRole,Organization): Common patterns = Participant
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

CoverageEligibilityResponse.request
Element Id CoverageEligibilityResponse.request
Definition

Reference to the original request resource.

Cardinality 1..1
Type Reference ( CoverageEligibilityRequest )
Requirements

Needed to allow the response to be linked to the request.

Summary true
CoverageEligibilityResponse.outcome
Element Id CoverageEligibilityResponse.outcome
Definition

The outcome of the request processing.

Cardinality 1..1
Terminology Binding RemittanceOutcome ( Required )
Type code
Requirements

To advise the requestor of an overall processing outcome.

Summary true
Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

CoverageEligibilityResponse.disposition
Element Id CoverageEligibilityResponse.disposition
Definition

A human readable description of the status of the adjudication.

Cardinality 0..1
Type string
Requirements

Provided for user display.

CoverageEligibilityResponse.insurer
Element Id CoverageEligibilityResponse.insurer
Definition

The Insurer who issued the coverage in question and is the author of the response.

Cardinality 1..1
Type Reference ( Organization )
Requirements

Need to identify the author.

Summary true
CoverageEligibilityResponse.insurance
Element Id CoverageEligibilityResponse.insurance
Definition

Financial instruments for reimbursement for the health care products and services.

Cardinality 0..*
Requirements

There must be at least one coverage for which eligibility is requested.

Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

CoverageEligibilityResponse.insurance.coverage
Element Id CoverageEligibilityResponse.insurance.coverage
Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Cardinality 1..1
Type Reference ( Coverage )
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Summary true
CoverageEligibilityResponse.insurance.inforce
Element Id CoverageEligibilityResponse.insurance.inforce
Definition

Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.

Cardinality 0..1
Type boolean
Requirements

Needed to convey the answer to the eligibility validation request.

CoverageEligibilityResponse.insurance.benefitPeriod
Element Id CoverageEligibilityResponse.insurance.benefitPeriod
Definition

The term of the benefits documented in this response.

Cardinality 0..1
Type Period
Requirements

Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

CoverageEligibilityResponse.insurance.item
Element Id CoverageEligibilityResponse.insurance.item
Definition

Benefits and optionally current balances, and authorization details by category or service.

Cardinality 0..*
Invariants
Defined on this element
ces-1 Rule SHALL contain a category or a billcode but not both. category.exists() xor productOrService.exists()
CoverageEligibilityResponse.insurance.item.category
Element Id CoverageEligibilityResponse.insurance.item.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Cardinality 0..1
Terminology Binding Benefit Category Codes ( Example )
Type CodeableConcept
Requirements

Needed to convey the category of service or product for which eligibility is sought.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

CoverageEligibilityResponse.insurance.item.productOrService
Element Id CoverageEligibilityResponse.insurance.item.productOrService
Definition

This contains the product, service, drug or other billing code for the item.

Cardinality 0..1
Terminology Binding USCLS Codes ( Example )
Type CodeableConcept
Requirements

Needed to convey the actual service or product for which eligibility is sought.

Alternate Names Drug Code; Bill Code; Service Code
Comments

Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).

CoverageEligibilityResponse.insurance.item.modifier
Element Id CoverageEligibilityResponse.insurance.item.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Cardinality 0..*
Terminology Binding Modifier type Codes ( Example )
Type CodeableConcept
Requirements

To support provision of the item or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

CoverageEligibilityResponse.insurance.item.provider
Element Id CoverageEligibilityResponse.insurance.item.provider
Definition

The practitioner who is eligible for the provision of the product or service.

Cardinality 0..1
Type Reference ( Practitioner | PractitionerRole )
Patterns Reference(Practitioner,PractitionerRole): Common patterns = Participant
Requirements

Needed to convey the eligible provider.

CoverageEligibilityResponse.insurance.item.excluded
Element Id CoverageEligibilityResponse.insurance.item.excluded
Definition

True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

Cardinality 0..1
Type boolean
Requirements

Needed to identify items that are specifically excluded from the coverage.

CoverageEligibilityResponse.insurance.item.name
Element Id CoverageEligibilityResponse.insurance.item.name
Definition

A short name or tag for the benefit.

Cardinality 0..1
Type string
Requirements

Required to align with other plan names.

Comments

For example: MED01, or DENT2.

CoverageEligibilityResponse.insurance.item.description
Element Id CoverageEligibilityResponse.insurance.item.description
Definition

A richer description of the benefit or services covered.

Cardinality 0..1
Type string
Requirements

Needed for human readable reference.

Comments

For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

CoverageEligibilityResponse.insurance.item.network
Element Id CoverageEligibilityResponse.insurance.item.network
Definition

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Cardinality 0..1
Terminology Binding Network Type Codes ( Example )
Type CodeableConcept
Requirements

Needed as in or out of network providers are treated differently under the coverage.

CoverageEligibilityResponse.insurance.item.unit
Element Id CoverageEligibilityResponse.insurance.item.unit
Definition

Indicates if the benefits apply to an individual or to the family.

Cardinality 0..1
Terminology Binding Unit Type Codes ( Example )
Type CodeableConcept
Requirements

Needed for the understanding of the benefits.

CoverageEligibilityResponse.insurance.item.term
Element Id CoverageEligibilityResponse.insurance.item.term
Definition

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Cardinality 0..1
Terminology Binding Benefit Term Codes ( Example )
Type CodeableConcept
Requirements

Needed for the understanding of the benefits.

CoverageEligibilityResponse.insurance.item.benefit
Element Id CoverageEligibilityResponse.insurance.item.benefit
Definition

Benefits used to date.

Cardinality 0..*
CoverageEligibilityResponse.insurance.item.benefit.type
Element Id CoverageEligibilityResponse.insurance.item.benefit.type
Definition

Classification of benefit being provided.

Cardinality 1..1
Terminology Binding Benefit Type Codes ( Example )
Type CodeableConcept
Requirements

Needed to convey the nature of the benefit.

Comments

For example: deductible, visits, benefit amount.

CoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Element Id CoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Definition

The quantity of the benefit which is permitted under the coverage.

Cardinality 0..1
Type unsignedInt | string | Money
[x] Note See Choice of Data Types for further information about how to use [x]
Requirements

Needed to convey the benefits offered under the coverage.

CoverageEligibilityResponse.insurance.item.benefit.used[x]
Element Id CoverageEligibilityResponse.insurance.item.benefit.used[x]
Definition

The quantity of the benefit which have been consumed to date.

Cardinality 0..1
Type unsignedInt | string | Money
[x] Note See Choice of Data Types for further information about how to use [x]
Requirements

Needed to convey the benefits consumed to date.

CoverageEligibilityResponse.insurance.item.authorizationRequired
Element Id CoverageEligibilityResponse.insurance.item.authorizationRequired
Definition

A boolean flag indicating whether a preauthorization is required prior to actual service delivery.

Cardinality 0..1
Type boolean
Requirements

Needed to convey that preauthorization is required.

CoverageEligibilityResponse.insurance.item.authorizationSupporting
Element Id CoverageEligibilityResponse.insurance.item.authorizationSupporting
Definition

Codes or comments regarding information or actions associated with the preauthorization.

Cardinality 0..*
Terminology Binding CoverageEligibilityResponse Auth Support Codes ( Example )
Type CodeableConcept
Requirements

Needed to inform the provider of collateral materials or actions needed for preauthorization.

CoverageEligibilityResponse.insurance.item.authorizationUrl
Element Id CoverageEligibilityResponse.insurance.item.authorizationUrl
Definition

A web location for obtaining requirements or descriptive information regarding the preauthorization.

Cardinality 0..1
Type uri
Requirements

Needed to enable insurers to advise providers of informative information.

CoverageEligibilityResponse.preAuthRef
Element Id CoverageEligibilityResponse.preAuthRef
Definition

A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.

Cardinality 0..1
Type string
Requirements

To provide any preauthorization reference for provider use.

CoverageEligibilityResponse.form
Element Id CoverageEligibilityResponse.form
Definition

A code for the form to be used for printing the content.

Cardinality 0..1
Terminology Binding Forms ( Example )
Type CodeableConcept
Requirements

Needed to specify the specific form used for producing output for this response.

Comments

May be needed to identify specific jurisdictional forms.

CoverageEligibilityResponse.error
Element Id CoverageEligibilityResponse.error
Definition

Errors encountered during the processing of the request.

Cardinality 0..*
Requirements

Need to communicate processing issues to the requestor.

CoverageEligibilityResponse.error.code
Element Id CoverageEligibilityResponse.error.code
Definition

An error code,from a specified code system, which details why the eligibility check could not be performed.

Cardinality 1..1
Terminology Binding AdjudicationError ( Example )
Type CodeableConcept
Requirements

Required to convey processing errors.