CoverageEligibilityRequest

Introduction

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:

• 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.

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

Background and Context

Provides additional detail on exactly how the resource is to be used

StructureDefinition

Elements (Simplified)

• CoverageEligibilityRequest [0..*]: - CoverageEligibilityRequest resource
• CoverageEligibilityRequest.identifier [0..*]: Identifier Business Identifier for coverage eligiblity request
• CoverageEligibilityRequest.status [1..1]: code required:fm-status active | cancelled | draft | entered-in-error
• CoverageEligibilityRequest.statusReason [0..1]: string Reason for status change
• CoverageEligibilityRequest.priority [0..1]: CodeableConcept example:process-priority Desired processing priority
• CoverageEligibilityRequest.purpose [1..*]: code required:eligibilityrequest-purpose auth-requirements | benefits | discovery | validation
• CoverageEligibilityRequest.patient [1..1]: Reference(Patient) Intended recipient of products and services
• CoverageEligibilityRequest.event [0..*]: BackboneElement Event information
• CoverageEligibilityRequest.event.type [1..1]: CodeableConcept example:datestype Specific event
• CoverageEligibilityRequest.event.when[x] [1..1]: dateTime, Period Occurance date or period
• CoverageEligibilityRequest.serviced[x] [0..1]: date, Period Estimated date or dates of service
• CoverageEligibilityRequest.created [1..1]: dateTime Creation date
• CoverageEligibilityRequest.enterer [0..1]: [Reference(Practitioner](/Reference(Practitioner), PractitionerRole)) Author
• CoverageEligibilityRequest.provider [0..1]: [Reference(Practitioner](/Reference(Practitioner), PractitionerRole, Organization)) Party responsible for the request
• CoverageEligibilityRequest.insurer [1..1]: Reference(Organization) Coverage issuer
• CoverageEligibilityRequest.facility [0..1]: Reference(Location) Servicing facility
• CoverageEligibilityRequest.supportingInfo [0..*]: BackboneElement Supporting information
• CoverageEligibilityRequest.supportingInfo.sequence [1..1]: positiveInt Information instance identifier
• CoverageEligibilityRequest.supportingInfo.information [1..1]: Reference(Resource) Data to be provided
• CoverageEligibilityRequest.supportingInfo.appliesToAll [0..1]: boolean Applies to all items
• CoverageEligibilityRequest.insurance [0..*]: BackboneElement Patient insurance information
• CoverageEligibilityRequest.insurance.focal [0..1]: boolean Applicable coverage
• CoverageEligibilityRequest.insurance.coverage [1..1]: Reference(Coverage) Insurance information
• CoverageEligibilityRequest.insurance.businessArrangement [0..1]: string Additional provider contract number
• CoverageEligibilityRequest.item [0..*]: BackboneElement Item to be evaluated for eligibiity
• CoverageEligibilityRequest.item.supportingInfoSequence [0..*]: positiveInt Applicable exception or supporting information
• CoverageEligibilityRequest.item.category [0..1]: CodeableConcept example:ex-benefitcategory Benefit classification
• CoverageEligibilityRequest.item.productOrService [0..1]: CodeableConcept example:service-uscls Billing, service, product, or drug code
• CoverageEligibilityRequest.item.modifier [0..*]: CodeableConcept example:claim-modifiers Product or service billing modifiers
• CoverageEligibilityRequest.item.provider [0..1]: [Reference(Practitioner](/Reference(Practitioner), PractitionerRole)) Perfoming practitioner
• CoverageEligibilityRequest.item.quantity [0..1]: Quantity(SimpleQuantity) Count of products or services
• CoverageEligibilityRequest.item.unitPrice [0..1]: Money Fee, charge or cost per item
• CoverageEligibilityRequest.item.facility [0..1]: [Reference(Location](/Reference(Location), Organization)) Servicing facility
• CoverageEligibilityRequest.item.diagnosis [0..*]: BackboneElement Applicable diagnosis
• CoverageEligibilityRequest.item.diagnosis.diagnosis[x] [0..1]: CodeableConcept, Reference(Condition) example:icd-10 Nature of illness or problem
• CoverageEligibilityRequest.item.detail [0..*]: Reference(Resource) Product or service details

Mappings

• CoverageEligibilityRequest Mappings — 23 mapping entries

Operations

• submit — Submit an EligibilityRequest resource for assessment — This operation is used to submit an EligibilityRequest for assessment either as a single EligibilityRequest resource instance or as a Bundle containing the EligibilityRequest and other referenced resources, or Bundle containing a batch of EligibilityRequest resources, either as single EligibilityRequests resources or Bundle resources, for processing.

Full Operations

Resource Packs

list-CoverageEligibilityRequest-packs.xml

<?xml version="1.0" encoding="UTF-8"?>

<List xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../publish/List.xsd">
  <id value="CoverageEligibilityRequest-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

• created — date — The creation date for the EOB — CoverageEligibilityRequest.created
• enterer — reference — The party who is responsible for the request — CoverageEligibilityRequest.enterer
• facility — reference — Facility responsible for the goods and services — CoverageEligibilityRequest.facility
• identifier — token — The business identifier of the Eligibility — CoverageEligibilityRequest.identifier
• patient — reference — The reference to the patient — CoverageEligibilityRequest.patient
• provider — reference — The reference to the provider — CoverageEligibilityRequest.provider
• status — token — The status of the EligibilityRequest — CoverageEligibilityRequest.status

Full Search Parameters

Examples

• 52345 — coverageeligibilityrequest-example — General Person Primary Coverage Example
• 52346 — coverageeligibilityrequest-example-2 — Primary Coverage specifying Benefit Example
• coverageeligibilityrequest-example — coverageeligibilityrequest-example
• coverageeligibilityrequest-example-2 — coverageeligibilityrequest-example-2
• coverageeligibilityrequest-examples-header — coverageeligibilityrequest-examples-header

Full Examples

Mapping Exceptions

coverageeligibilityrequest-fivews-mapping-exceptions.xml

Unmapped Elements

• FiveWs.what — Unknown
• FiveWs.actor — Unknown
• FiveWs.cause — Unknown
• FiveWs.version — Unknown
• FiveWs.witness — Unknown
• FiveWs.context — Unknown
• FiveWs.init — Unknown
• FiveWs.why — Unknown
• FiveWs.grade — Unknown
• FiveWs.planned — Unknown

coverageeligibilityrequest-request-mapping-exceptions.xml

Divergent Elements

• Request.identifier → CoverageEligibilityRequest.identifier
  • summary | reason=Unknown | pattern=true
  • shortUnmatched | reason=Unknown | pattern=Business Identifier for coverage eligibility request | resource=Business Identifier for coverage eligiblity request
  • definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this coverage eligibility request by the author and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server. | resource=A unique identifier assigned to this coverage eligiblity request.
  • commentsUnmatched | reason=Unknown | pattern=The identifier.type element is used to distinguish between the identifiers assigned by the requester/placer and the performer/filler.

Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

• requirementsUnmatched | reason=Unknown | pattern=Allows identification of the coverage eligibility request as it is known by various participating systems and in a way that remains consistent across servers. | resource=Allows coverage eligibility requests to be distinguished and referenced.
• Request.status → CoverageEligibilityRequest.status
  • shortUnmatched | reason=Unknown | pattern=draft | active | on-hold | revoked | completed | entered-in-error | unknown | resource=active | cancelled | draft | entered-in-error
  • definitionUnmatched | reason=Unknown | pattern=The current state of the coverage eligibility request. | resource=The status of the resource instance.
  • commentsUnmatched | reason=Unknown | pattern=The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, completed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding]](s) or using the]] resource. A nominal state-transition diagram can be found in the] documentation Unknown does not represent "other" - one of the defined statuses must apply. Unknown is used when the authoring system is not sure what the current status is. A status of 'active' when doNotPerform is true means that the request to not perform is currently in force.

A status of completed for a "doNotPerform" request indicates that the period of non-performance is now satisfied and the request no longer holds. | resource=This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

• Request.priority → CoverageEligibilityRequest.priority
  • missingTypes | reason=Unknown | pattern=code
  • extraTypes | reason=Unknown
  • summary | reason=Unknown | pattern=true
  • bindingStrength | reason=Unknown | pattern=required
  • shortUnmatched | reason=Unknown | pattern=routine | urgent | asap | stat | resource=Desired processing priority
  • definitionUnmatched | reason=Unknown | pattern=Indicates how quickly the coverage eligibility request should be addressed with respect to other requests. | resource=When the requestor expects the processor to complete processing.
• Request.subject → CoverageEligibilityRequest.patient
  • missingTypes | reason=Unknown | pattern=Reference(Group)
  • shortUnmatched | reason=Unknown | pattern=Individual the service is ordered/prohibited for | resource=Intended recipient of products and services
  • definitionUnmatched | reason=Unknown | pattern=The individual or set of individuals the action is to be performed/not performed on or for. | resource=The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.
  • requirementsUnmatched | reason=Unknown | pattern=Links the request to the Patient context. | resource=Required to provide context and coverage validation.
• Request.authoredOn → CoverageEligibilityRequest.created
  • shortUnmatched | reason=Unknown | pattern=When request was created/transitioned to active | resource=Creation date
  • definitionUnmatched | reason=Unknown | pattern=For draft coverage eligibility requests, indicates the date of initial creation. For requests with other statuses, indicates the date of activation. | resource=The date when this resource was created.
• Request.requester → CoverageEligibilityRequest.provider
  • missingTypes | reason=Unknown | pattern=Reference(Patient, RelatedPerson, Device)
  • summary | reason=Unknown | pattern=true
  • shortUnmatched | reason=Unknown | pattern=Who/what is requesting service | resource=Party responsible for the request
  • definitionUnmatched | reason=Unknown | pattern=Who initiated the {{request}} and has responsibility for its activation. | resource=The provider which is responsible for the request.
• Request.requester → CoverageEligibilityRequest.item.provider
  • missingTypes | reason=Unknown | pattern=Reference(Organization, Patient, RelatedPerson, Device)
  • summary | reason=Unknown | pattern=true
  • shortUnmatched | reason=Unknown | pattern=Who/what is requesting service | resource=Perfoming practitioner
  • definitionUnmatched | reason=Unknown | pattern=Who initiated the {{request}} and has responsibility for its activation. | resource=The practitioner who is responsible for the product or service to be rendered to the patient.
• Request.performer → CoverageEligibilityRequest.insurer
  • missingTypes | reason=Unknown | pattern=Reference(Practitioner, PractitionerRole, CareTeam, HealthcareService, Patient, Device, RelatedPerson)
  • shortUnmatched | reason=Unknown | pattern=Specific desired (non)performer | resource=Coverage issuer
  • definitionUnmatched | reason=Unknown | pattern=Indicates who or what is being asked to perform (or not perform) the {{request}}. | resource=The Insurer who issued the coverage in question and is the recipient of the request.

Unmapped Elements

• Request.intent — Unknown
• Request.insurance — Unknown
• Request.occurrence — Unknown
• Request.groupIdentifier — Unknown
• Request.deliverTo — Unknown
• Request.replaces — Unknown
• Request.supportingInfo — Unknown
• Request.note — Unknown
• Request.basedOn — Unknown
• Request.encounter — Unknown
• Request.category — Unknown
• Request.reason — Unknown
• Request.reported — Unknown
• Request.relevantHistory — Unknown
• Request.code — Unknown
• Request.statusReason — Unknown
• Request.performerType — Unknown
• Request.doNotPerform — Unknown
• Request.product — Unknown