Release 4 5 Preview #2
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13.3 Resource CoverageEligibilityResponse - Content

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

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

The CoverageEligibilityResponse resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy benefit details as well as the ability for the insurer to indicate whether the insurance provides benefits for requested types of services or requires preauthorization and if so what supporting information may be required.

The CoverageEligibilityResponse 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.

CoverageEligibilityResponse should be used to respond to a request on whether the patient's coverage is inforce, whether it is valid at this or a specified date, or to report the benefit details or preauthorization requirements associated with a coverage.

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 CoverageEligibilityRequest should be used instead.

The ClaimResponse resource is an insurer's adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages.

For reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used .

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 CoverageEligibilityResponse.

The eClaim domain includes a number of related resources

CoverageEligibilityResponse 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.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
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.
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.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.

No resources refer to this resource directly.

This resource implements the Event pattern.

Structure

Name Flags Card. Type Description & Constraints doco
. . CoverageEligibilityResponse TU DomainResource CoverageEligibilityResponse 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 )
. . . purpose Σ 1..* code auth-requirements | benefits | discovery | validation
EligibilityResponsePurpose ( Required )
. . . 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 ( CoverageEligibilityRequest ) Eligibility request reference
. . . outcome Σ 1..1 code queued | complete | error | partial
RemittanceOutcome ( Required )
. . . disposition 0..1 string Disposition Message
. . . insurer Σ 1..1 Reference ( Organization ) Coverage issuer
. . . insurance 0..* BackboneElement Patient insurance information
. . . . 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 I 0..* BackboneElement Benefits and authorization details
+ Rule: SHALL contain a category or a billcode but not both.
. . . . . 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 ) 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
Network Type Codes ( Example )
. . . . . unit 0..1 CodeableConcept Individual or family
Unit Type Codes ( Example )
. . . . . term 0..1 CodeableConcept Annual or lifetime
Benefit Term Codes ( Example )
. . . . . benefit 0..* BackboneElement Benefit Summary
. . . . . . type 1..1 CodeableConcept Benefit classification
Benefit Type Codes ( Example )
. . . . . . 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
CoverageEligibilityResponse Auth Support Codes ( Example )
. . . . . authorizationUrl 0..1 uri Preauthorization requirements endpoint
. . . preAuthRef 0..1 string Preauthorization reference
. . . form 0..1 CodeableConcept Printed form identifier
Forms ( Example )
. . . error 0..* BackboneElement Processing errors
. . . . code 1..1 CodeableConcept Error code detailing processing issues
AdjudicationError ( Example )

doco Documentation for this format

UML Diagram ( Legend )

CoverageEligibilityResponse ( 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 ! » 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) EligibilityResponsePurpose ! » 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 this resource was created created : dateTime [1..1] The provider which is responsible for the request requestor : Reference [0..1] « Practitioner | PractitionerRole | Organization » Reference to the original request resource request : Reference [1..1] « CoverageEligibilityRequest » The outcome of the request processing outcome : code [1..1] « The outcome of the processing. (Strength=Required) RemittanceOutcome ! » A human readable description of the status of the adjudication disposition : string [0..1] The Insurer who issued the coverage in question and is the author of the response insurer : Reference [1..1] « Organization » A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred preAuthRef : string [0..1] A code for the form to be used for printing the content form : CodeableConcept [0..1] « The forms codes. (Strength=Example) Form ?? » Insurance 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 » Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates inforce : boolean [0..1] The term of the benefits documented in this response benefitPeriod : Period [0..1] Items 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 eligible for the provision of the product or service provider : Reference [0..1] « Practitioner | PractitionerRole » 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 excluded : boolean [0..1] A short name or tag for the benefit name : string [0..1] A richer description of the benefit or services covered description : string [0..1] Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers network : CodeableConcept [0..1] « Code to classify in or out of network services. (Strength=Example) NetworkTypeCodes ?? » Indicates if the benefits apply to an individual or to the family unit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. (Strength=Example) UnitTypeCodes ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits' term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. (Strength=Example) BenefitTermCodes ?? » A boolean flag indicating whether a preauthorization is required prior to actual service delivery authorizationRequired : boolean [0..1] Codes or comments regarding information or actions associated with the preauthorization authorizationSupporting : CodeableConcept [0..*] « Type of supporting information to provide with a preauthorization. (Strength=Example) CoverageEligibilityResponseAu... ?? » A web location for obtaining requirements or descriptive information regarding the preauthorization authorizationUrl : uri [0..1] Benefit Classification of benefit being provided type : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example) BenefitTypeCodes ?? » The quantity of the benefit which is permitted under the coverage allowed[x] : Type DataType [0..1] « unsignedInt | string | Money » The quantity of the benefit which have been consumed to date used[x] : Type DataType [0..1] « unsignedInt | string | Money » Errors An error code,from a specified code system, which details why the eligibility check could not be performed code : CodeableConcept [1..1] « The error codes for adjudication processing. (Strength=Example) Adjudication Error ?? » Benefits used to date benefit [0..*] Benefits and optionally current balances, and authorization details by category or service item [0..*] Financial instruments for reimbursement for the health care products and services insurance [0..*] Errors encountered during the processing of the request error [0..*]

XML Template

<CoverageEligibilityResponse 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 -->
 <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 Response creation date -->
 <</requestor>

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

 <request><!-- 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <insurance>  <!-- 0..* Patient insurance information -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
  <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
  <item>  <!-- 0..* Benefits and authorization details -->
   <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) Performing practitioner --></provider>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <benefit>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Benefit classification --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|string|Money Benefits used --></used[x]>
   </benefit>
   <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag -->
   <authorizationSupporting><!-- 0..* CodeableConcept Type of required supporting materials --></authorizationSupporting>
   <authorizationUrl value="[uri]"/><!-- 0..1 Preauthorization requirements endpoint -->
  </item>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <form><!-- 0..1 CodeableConcept Printed form identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</CoverageEligibilityResponse>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityResponse",
  // 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
  "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!  Response creation date
  "

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

  "request" : { Reference(CoverageEligibilityRequest) }, // R!  Eligibility request reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "insurance" : [{ // Patient insurance information
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "inforce" : <boolean>, // Coverage inforce indicator
    "benefitPeriod" : { Period }, // When the benefits are applicable
    "item" : [{ // Benefits and authorization details
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
      "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "benefit" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Benefit classification
        // allowed[x]: Benefits allowed. One of these 3:
        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 3:
        "usedUnsignedInt" : "<unsignedInt>"
        "usedString" : "<string>"
        "usedMoney" : { Money }
      }],
      "authorizationRequired" : <boolean>, // Authorization required flag
      "authorizationSupporting" : [{ CodeableConcept }], // Type of required supporting materials
      "authorizationUrl" : "<uri>" // Preauthorization requirements endpoint
    }]
  }],
  "preAuthRef" : "<string>", // Preauthorization reference
  "form" : { CodeableConcept }, // Printed form identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:CoverageEligibilityResponse;
  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:CoverageEligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityResponse.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityResponse.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityResponse.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityResponse.servicedDate [ date ]
    fhir:CoverageEligibilityResponse.servicedPeriod [ Period ]
  fhir:CoverageEligibilityResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:

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

  fhir:CoverageEligibilityResponse.request [ Reference(CoverageEligibilityRequest) ]; # 1..1 Eligibility request reference
  fhir:CoverageEligibilityResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:CoverageEligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:CoverageEligibilityResponse.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityResponse.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityResponse.insurance.inforce [ boolean ]; # 0..1 Coverage inforce indicator
    fhir:CoverageEligibilityResponse.insurance.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
    fhir:CoverageEligibilityResponse.insurance.item [ # 0..* Benefits and authorization details
      fhir:CoverageEligibilityResponse.insurance.item.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:CoverageEligibilityResponse.insurance.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:CoverageEligibilityResponse.insurance.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
      fhir:CoverageEligibilityResponse.insurance.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Performing practitioner
      fhir:CoverageEligibilityResponse.insurance.item.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:CoverageEligibilityResponse.insurance.item.name [ string ]; # 0..1 Short name for the benefit
      fhir:CoverageEligibilityResponse.insurance.item.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:CoverageEligibilityResponse.insurance.item.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:CoverageEligibilityResponse.insurance.item.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:CoverageEligibilityResponse.insurance.item.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:CoverageEligibilityResponse.insurance.item.benefit [ # 0..* Benefit Summary
        fhir:CoverageEligibilityResponse.insurance.item.benefit.type [ CodeableConcept ]; # 1..1 Benefit classification
        # CoverageEligibilityResponse.insurance.item.benefit.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedMoney [ Money ]
        # CoverageEligibilityResponse.insurance.item.benefit.used[x] : 0..1 Benefits used. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedMoney [ Money ]
      ], ...;
      fhir:CoverageEligibilityResponse.insurance.item.authorizationRequired [ boolean ]; # 0..1 Authorization required flag
      fhir:CoverageEligibilityResponse.insurance.item.authorizationSupporting [ CodeableConcept ], ... ; # 0..* Type of required supporting materials
      fhir:CoverageEligibilityResponse.insurance.item.authorizationUrl [ uri ]; # 0..1 Preauthorization requirements endpoint
    ], ...;
  ], ...;
  fhir:CoverageEligibilityResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:CoverageEligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:CoverageEligibilityResponse.error [ # 0..* Processing errors
    fhir:CoverageEligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since R3

CoverageEligibilityResponse
CoverageEligibilityResponse.status
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.4.0
CoverageEligibilityResponse.purpose
  • Change value set from http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.0 to http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.4.0
CoverageEligibilityResponse.outcome
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/remittance-outcome|4.4.0

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
. . CoverageEligibilityResponse TU DomainResource CoverageEligibilityResponse 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 )
. . . purpose Σ 1..* code auth-requirements | benefits | discovery | validation
EligibilityResponsePurpose ( Required )
. . . 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 ( CoverageEligibilityRequest ) Eligibility request reference
. . . outcome Σ 1..1 code queued | complete | error | partial
RemittanceOutcome ( Required )
. . . disposition 0..1 string Disposition Message
. . . insurer Σ 1..1 Reference ( Organization ) Coverage issuer
. . . insurance 0..* BackboneElement Patient insurance information
. . . . 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 I 0..* BackboneElement Benefits and authorization details
+ Rule: SHALL contain a category or a billcode but not both.
. . . . . 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 ) 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
Network Type Codes ( Example )
. . . . . unit 0..1 CodeableConcept Individual or family
Unit Type Codes ( Example )
. . . . . term 0..1 CodeableConcept Annual or lifetime
Benefit Term Codes ( Example )
. . . . . benefit 0..* BackboneElement Benefit Summary
. . . . . . type 1..1 CodeableConcept Benefit classification
Benefit Type Codes ( Example )
. . . . . . 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
CoverageEligibilityResponse Auth Support Codes ( Example )
. . . . . authorizationUrl 0..1 uri Preauthorization requirements endpoint
. . . preAuthRef 0..1 string Preauthorization reference
. . . form 0..1 CodeableConcept Printed form identifier
Forms ( Example )
. . . error 0..* BackboneElement Processing errors
. . . . code 1..1 CodeableConcept Error code detailing processing issues
AdjudicationError ( Example )

doco Documentation for this format

UML Diagram ( Legend )

CoverageEligibilityResponse ( 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 ! » 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) EligibilityResponsePurpose ! » 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 this resource was created created : dateTime [1..1] The provider which is responsible for the request requestor : Reference [0..1] « Practitioner | PractitionerRole | Organization » Reference to the original request resource request : Reference [1..1] « CoverageEligibilityRequest » The outcome of the request processing outcome : code [1..1] « The outcome of the processing. (Strength=Required) RemittanceOutcome ! » A human readable description of the status of the adjudication disposition : string [0..1] The Insurer who issued the coverage in question and is the author of the response insurer : Reference [1..1] « Organization » A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred preAuthRef : string [0..1] A code for the form to be used for printing the content form : CodeableConcept [0..1] « The forms codes. (Strength=Example) Form ?? » Insurance 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 » Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates inforce : boolean [0..1] The term of the benefits documented in this response benefitPeriod : Period [0..1] Items 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 eligible for the provision of the product or service provider : Reference [0..1] « Practitioner | PractitionerRole » 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 excluded : boolean [0..1] A short name or tag for the benefit name : string [0..1] A richer description of the benefit or services covered description : string [0..1] Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers network : CodeableConcept [0..1] « Code to classify in or out of network services. (Strength=Example) NetworkTypeCodes ?? » Indicates if the benefits apply to an individual or to the family unit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. (Strength=Example) UnitTypeCodes ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits' term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. (Strength=Example) BenefitTermCodes ?? » A boolean flag indicating whether a preauthorization is required prior to actual service delivery authorizationRequired : boolean [0..1] Codes or comments regarding information or actions associated with the preauthorization authorizationSupporting : CodeableConcept [0..*] « Type of supporting information to provide with a preauthorization. (Strength=Example) CoverageEligibilityResponseAu... ?? » A web location for obtaining requirements or descriptive information regarding the preauthorization authorizationUrl : uri [0..1] Benefit Classification of benefit being provided type : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example) BenefitTypeCodes ?? » The quantity of the benefit which is permitted under the coverage allowed[x] : Type DataType [0..1] « unsignedInt | string | Money » The quantity of the benefit which have been consumed to date used[x] : Type DataType [0..1] « unsignedInt | string | Money » Errors An error code,from a specified code system, which details why the eligibility check could not be performed code : CodeableConcept [1..1] « The error codes for adjudication processing. (Strength=Example) Adjudication Error ?? » Benefits used to date benefit [0..*] Benefits and optionally current balances, and authorization details by category or service item [0..*] Financial instruments for reimbursement for the health care products and services insurance [0..*] Errors encountered during the processing of the request error [0..*]

XML Template

<CoverageEligibilityResponse 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 -->
 <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 Response creation date -->
 <</requestor>

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

 <request><!-- 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <insurance>  <!-- 0..* Patient insurance information -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
  <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
  <item>  <!-- 0..* Benefits and authorization details -->
   <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) Performing practitioner --></provider>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <benefit>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Benefit classification --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|string|Money Benefits used --></used[x]>
   </benefit>
   <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag -->
   <authorizationSupporting><!-- 0..* CodeableConcept Type of required supporting materials --></authorizationSupporting>
   <authorizationUrl value="[uri]"/><!-- 0..1 Preauthorization requirements endpoint -->
  </item>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <form><!-- 0..1 CodeableConcept Printed form identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</CoverageEligibilityResponse>

JSON Template

{doco
  "resourceType" : "CoverageEligibilityResponse",
  // 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
  "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!  Response creation date
  "

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

  "request" : { Reference(CoverageEligibilityRequest) }, // R!  Eligibility request reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "insurance" : [{ // Patient insurance information
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "inforce" : <boolean>, // Coverage inforce indicator
    "benefitPeriod" : { Period }, // When the benefits are applicable
    "item" : [{ // Benefits and authorization details
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
      "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "benefit" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Benefit classification
        // allowed[x]: Benefits allowed. One of these 3:
        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 3:
        "usedUnsignedInt" : "<unsignedInt>"
        "usedString" : "<string>"
        "usedMoney" : { Money }
      }],
      "authorizationRequired" : <boolean>, // Authorization required flag
      "authorizationSupporting" : [{ CodeableConcept }], // Type of required supporting materials
      "authorizationUrl" : "<uri>" // Preauthorization requirements endpoint
    }]
  }],
  "preAuthRef" : "<string>", // Preauthorization reference
  "form" : { CodeableConcept }, // Printed form identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:CoverageEligibilityResponse;
  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:CoverageEligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityResponse.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityResponse.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityResponse.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityResponse.servicedDate [ date ]
    fhir:CoverageEligibilityResponse.servicedPeriod [ Period ]
  fhir:CoverageEligibilityResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:

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

  fhir:CoverageEligibilityResponse.request [ Reference(CoverageEligibilityRequest) ]; # 1..1 Eligibility request reference
  fhir:CoverageEligibilityResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:CoverageEligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:CoverageEligibilityResponse.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityResponse.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityResponse.insurance.inforce [ boolean ]; # 0..1 Coverage inforce indicator
    fhir:CoverageEligibilityResponse.insurance.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
    fhir:CoverageEligibilityResponse.insurance.item [ # 0..* Benefits and authorization details
      fhir:CoverageEligibilityResponse.insurance.item.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:CoverageEligibilityResponse.insurance.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:CoverageEligibilityResponse.insurance.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
      fhir:CoverageEligibilityResponse.insurance.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Performing practitioner
      fhir:CoverageEligibilityResponse.insurance.item.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:CoverageEligibilityResponse.insurance.item.name [ string ]; # 0..1 Short name for the benefit
      fhir:CoverageEligibilityResponse.insurance.item.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:CoverageEligibilityResponse.insurance.item.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:CoverageEligibilityResponse.insurance.item.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:CoverageEligibilityResponse.insurance.item.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:CoverageEligibilityResponse.insurance.item.benefit [ # 0..* Benefit Summary
        fhir:CoverageEligibilityResponse.insurance.item.benefit.type [ CodeableConcept ]; # 1..1 Benefit classification
        # CoverageEligibilityResponse.insurance.item.benefit.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedMoney [ Money ]
        # CoverageEligibilityResponse.insurance.item.benefit.used[x] : 0..1 Benefits used. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedMoney [ Money ]
      ], ...;
      fhir:CoverageEligibilityResponse.insurance.item.authorizationRequired [ boolean ]; # 0..1 Authorization required flag
      fhir:CoverageEligibilityResponse.insurance.item.authorizationSupporting [ CodeableConcept ], ... ; # 0..* Type of required supporting materials
      fhir:CoverageEligibilityResponse.insurance.item.authorizationUrl [ uri ]; # 0..1 Preauthorization requirements endpoint
    ], ...;
  ], ...;
  fhir:CoverageEligibilityResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:CoverageEligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:CoverageEligibilityResponse.error [ # 0..* Processing errors
    fhir:CoverageEligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since Release 3

CoverageEligibilityResponse
CoverageEligibilityResponse.status
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.4.0
CoverageEligibilityResponse.purpose
  • Change value set from http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.0 to http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.4.0
CoverageEligibilityResponse.outcome
  • Change value set from http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/remittance-outcome|4.4.0

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
CoverageEligibilityResponse.status A code specifying the state of the resource instance. Required FinancialResourceStatusCodes
CoverageEligibilityResponse.purpose A code specifying the types of information being requested. Required EligibilityResponsePurpose
CoverageEligibilityResponse.outcome The outcome of the processing. Required RemittanceOutcome
CoverageEligibilityResponse.insurance.item.category Benefit categories such as: oral, medical, vision etc. Example BenefitCategoryCodes
CoverageEligibilityResponse.insurance.item.productOrService Allowable service and product codes. Example USCLSCodes
CoverageEligibilityResponse.insurance.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
CoverageEligibilityResponse.insurance.item.network Code to classify in or out of network services. Example NetworkTypeCodes
CoverageEligibilityResponse.insurance.item.unit Unit covered/serviced - individual or family. Example UnitTypeCodes
CoverageEligibilityResponse.insurance.item.term Coverage unit - annual, lifetime. Example BenefitTermCodes
CoverageEligibilityResponse.insurance.item.benefit.type Deductable, visits, co-pay, etc. Example BenefitTypeCodes
CoverageEligibilityResponse.insurance.item.authorizationSupporting Type of supporting information to provide with a preauthorization. Example CoverageEligibilityResponseAuthSupportCodes
CoverageEligibilityResponse.form The forms codes. Example Form Codes
CoverageEligibilityResponse.error.code The error codes for adjudication processing. Example Adjudication Error Codes

id Level Location Description Expression
ces-1 Rule CoverageEligibilityResponse.insurance.item SHALL contain a category or a billcode but not both. category.exists() xor productOrService.exists()

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 CoverageEligibilityResponse.created
disposition N string The contents of the disposition message CoverageEligibilityResponse.disposition
identifier token The business identifier CoverageEligibilityResponse.identifier
insurer reference The organization which generated this resource CoverageEligibilityResponse.insurer
( Organization )
outcome N token The processing outcome CoverageEligibilityResponse.outcome
patient reference The reference to the patient CoverageEligibilityResponse.patient
( Patient )
request reference The EligibilityRequest reference CoverageEligibilityResponse.request
( CoverageEligibilityRequest )
requestor reference The EligibilityRequest provider CoverageEligibilityResponse.requestor
( Practitioner , Organization , PractitionerRole )
status N token The EligibilityRequest status CoverageEligibilityResponse.status