Resource type: coverageeligibilityrequest

Description

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.

Elements

PathShortDefinitionComments
CoverageEligibilityRequest resourceThe 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.
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.
priorityDesired processing priorityWhen the requestor expects the processor to complete processing.
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.1..1.
serviced[x]Estimated date or dates of serviceThe date or dates when the enclosed suite of services were performed or completed.
createdCreation dateThe date when this resource was created.
entererAuthorPerson who created the request.
providerParty 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 eligibility request but not necessarily professionally responsible for the provision of the individual products and services listed below.
insurerCoverage issuerThe Insurer who issued the coverage in question and is the recipient of the request.
facilityServicing facilityFacility where the services are intended to be provided.
supportingInfoSupporting informationAdditional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.Often there are multiple jurisdiction specific valuesets which are required.
supportingInfo.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.
supportingInfo.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.
supportingInfo.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.
supportingInfo.sequenceInformation instance identifierA number to uniquely identify supporting information entries.
supportingInfo.informationData to be providedAdditional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.
supportingInfo.appliesToAllApplies to all itemsThe supporting materials are applicable for all detail items, product/servce categories and specific billing codes.
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.focalApplicable coverageA flag to indicate that this Coverage is to be used for evaluation of this request when set to true.A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for evaluating this request. Other requests would be created to request evaluation against the other listed policies.
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.businessArrangementAdditional provider contract numberA business agreement number established between the provider and the insurer for special business processing purposes.
itemItem to be evaluated for eligibiityService categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor.
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.
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.
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.
item.supportingInfoSequenceApplicable exception or supporting informationExceptions, special conditions and supporting information applicable for this service or product line.
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.
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).
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.
item.providerPerfoming practitionerThe practitioner who is responsible for the product or service to be rendered to the patient.
item.quantityCount of products or servicesThe number of repetitions of a service or product.
item.unitPriceFee, charge or cost per itemThe amount charged to the patient by the provider for a single unit.
item.facilityServicing facilityFacility where the services will be provided.
item.diagnosisApplicable diagnosisPatient diagnosis for which care is sought.
item.diagnosis.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.
item.diagnosis.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.
item.diagnosis.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.
item.diagnosis.diagnosis[x]Nature of illness or problemThe nature of illness or problem in a coded form or as a reference to an external defined Condition.
item.detailProduct or service detailsThe plan/proposal/order describing the proposed service in detail.

Scope and Usage

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

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

Boundaries and Relationships

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.


Search Parameters

createdThe creation date for the EOBCoverageEligibilityRequest.created
entererThe party who is responsible for the requestCoverageEligibilityRequest.enterer
facilityFacility responsible for the goods and servicesCoverageEligibilityRequest.facility
identifierThe business identifier of the EligibilityCoverageEligibilityRequest.identifier
patientThe reference to the patientCoverageEligibilityRequest.patient
providerThe reference to the providerCoverageEligibilityRequest.provider
statusThe status of the EligibilityRequestCoverageEligibilityRequest.status

Extension Definitions

These are extension definitions for this resource defined by the spec