Resource type: coverageeligibilityresponse

Description

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

Elements

PathShortDefinitionComments
CoverageEligibilityResponse resourceThis resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.
identifierBusiness Identifier for coverage eligiblity requestA unique identifier assigned to this coverage eligiblity request.
statusactive | cancelled | draft | entered-in-errorThe status of the resource instance.This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
purposeauth-requirements | benefits | discovery | validationCode 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.
patientIntended recipient of products and servicesThe party who is the beneficiary of the supplied coverage and for whom eligibility is sought.
serviced[x]Estimated date or dates of serviceThe date or dates when the enclosed suite of services were performed or completed.
createdResponse creation dateThe date this resource was created.
requestorParty responsible for the requestThe provider which is responsible for the request.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.
requestEligibility request referenceReference to the original request resource.
outcomequeued | complete | error | partialThe outcome of the request processing.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).
dispositionDisposition MessageA human readable description of the status of the adjudication.
insurerCoverage issuerThe Insurer who issued the coverage in question and is the author of the response.
insurancePatient insurance informationFinancial instruments for reimbursement for the health care products and services.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.
insurance.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
insurance.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.coverageInsurance informationReference 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.
insurance.inforceCoverage inforce indicatorFlag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.
insurance.benefitPeriodWhen the benefits are applicableThe term of the benefits documented in this response.
insurance.itemBenefits and authorization detailsBenefits and optionally current balances, and authorization details by category or service.
insurance.item.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
insurance.item.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.item.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.item.categoryBenefit classificationCode to identify the general type of benefits under which products and services are provided.Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
insurance.item.productOrServiceBilling, service, product, or drug codeThis contains the product, service, drug or other billing code for the item.Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).
insurance.item.modifierProduct or service billing modifiersItem typification or modifiers codes to convey additional context for the product or service.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.
insurance.item.providerPerforming practitionerThe practitioner who is eligible for the provision of the product or service.
insurance.item.excludedExcluded from the planTrue if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
insurance.item.nameShort name for the benefitA short name or tag for the benefit.For example: MED01, or DENT2.
insurance.item.descriptionDescription of the benefit or services coveredA richer description of the benefit or services covered.For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
insurance.item.networkIn or out of networkIs a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
insurance.item.unitIndividual or familyIndicates if the benefits apply to an individual or to the family.
insurance.item.termAnnual or lifetimeThe term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
insurance.item.benefitBenefit SummaryBenefits used to date.
insurance.item.benefit.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
insurance.item.benefit.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.item.benefit.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.item.benefit.typeBenefit classificationClassification of benefit being provided.For example: deductible, visits, benefit amount.
insurance.item.benefit.allowed[x]Benefits allowedThe quantity of the benefit which is permitted under the coverage.
insurance.item.benefit.used[x]Benefits usedThe quantity of the benefit which have been consumed to date.
insurance.item.authorizationRequiredAuthorization required flagA boolean flag indicating whether a preauthorization is required prior to actual service delivery.
insurance.item.authorizationSupportingType of required supporting materialsCodes or comments regarding information or actions associated with the preauthorization.
insurance.item.authorizationUrlPreauthorization requirements endpointA web location for obtaining requirements or descriptive information regarding the preauthorization.
preAuthRefPreauthorization referenceA reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.
formPrinted form identifierA code for the form to be used for printing the content.May be needed to identify specific jurisdictional forms.
errorProcessing errorsErrors encountered during the processing of the request.
error.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
error.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
error.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
error.codeError code detailing processing issuesAn error code,from a specified code system, which details why the eligibility check could not be performed.

Scope and Usage

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

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

Boundaries and Relationships

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.


Search Parameters

createdThe creation dateCoverageEligibilityResponse.created
dispositionThe contents of the disposition messageCoverageEligibilityResponse.disposition
identifierThe business identifierCoverageEligibilityResponse.identifier
insurerThe organization which generated this resourceCoverageEligibilityResponse.insurer
outcomeThe processing outcomeCoverageEligibilityResponse.outcome
patientThe reference to the patientCoverageEligibilityResponse.patient
requestThe EligibilityRequest referenceCoverageEligibilityResponse.request
requestorThe EligibilityRequest providerCoverageEligibilityResponse.requestor
statusThe EligibilityRequest statusCoverageEligibilityResponse.status

Extension Definitions

These are extension definitions for this resource defined by the spec