--- type: "resource" title: "CoverageEligibilityResponse" resource: "CoverageEligibilityResponse" --- # CoverageEligibilityResponse ## Introduction ## 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.](workflow#event) ### Additional Information Additional information regarding electronic coverage eligibility content and usage may be found at: - [Financial Resource Status Lifecycle](financial-module#resource-status): how .status is used in the financial resources. - [Subrogation](financial-module#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](financial-module#cob): how eClaims may handle multiple patient insurance coverages. - [Batches](financial-module#batch): how eClaims may handle batches of eligibility, claims and responses. - [Attachments and Supporting Information](financial-module#attachments): 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 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](coverageeligibilityrequest) should be used instead. The [ClaimResponse](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](explanationofbenefit) should be used . The [Coverage](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](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](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](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](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. | ## Background and Context Provides additional detail on exactly how the resource is to be used ## StructureDefinition ### Elements (Simplified) - **[CoverageEligibilityResponse](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse)** [0..*]: - CoverageEligibilityResponse resource - **[CoverageEligibilityResponse.identifier](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.identifier)** [0..*]: [Identifier](/Identifier) Business Identifier for coverage eligiblity request - **[CoverageEligibilityResponse.status](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.status)** [1..1]: [code](/code) required:[fm-status](/valueset-fm-status) active | cancelled | draft | entered-in-error - **[CoverageEligibilityResponse.statusReason](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.statusReason)** [0..1]: [string](/string) Reason for status change - **[CoverageEligibilityResponse.purpose](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.purpose)** [1..*]: [code](/code) required:[eligibilityresponse-purpose](/valueset-eligibilityresponse-purpose) auth-requirements | benefits | discovery | validation - **[CoverageEligibilityResponse.patient](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.patient)** [1..1]: Reference([Patient](/Patient)) Intended recipient of products and services - **[CoverageEligibilityResponse.event](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.event)** [0..*]: [BackboneElement](/BackboneElement) Event information - **[CoverageEligibilityResponse.event.type](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.event.type)** [1..1]: [CodeableConcept](/CodeableConcept) preferred:[datestype](/valueset-datestype) Specific event - **[CoverageEligibilityResponse.event.when[x]](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.event.when%5Bx%5D)** [1..1]: [dateTime](/dateTime), [Period](/Period) Occurance date or period - **[CoverageEligibilityResponse.serviced[x]](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.serviced%5Bx%5D)** [0..1]: [date](/date), [Period](/Period) Estimated date or dates of service - **[CoverageEligibilityResponse.created](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.created)** [1..1]: [dateTime](/dateTime) Response creation date - **[CoverageEligibilityResponse.requestor](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.requestor)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Party responsible for the request - **[CoverageEligibilityResponse.request](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.request)** [0..1]: Reference([CoverageEligibilityRequest](/CoverageEligibilityRequest)) Eligibility request reference - **[CoverageEligibilityResponse.outcome](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.outcome)** [1..1]: [code](/code) required:[eligibility-outcome](/valueset-eligibility-outcome) queued | complete | error | partial - **[CoverageEligibilityResponse.disposition](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.disposition)** [0..1]: [string](/string) Disposition Message - **[CoverageEligibilityResponse.insurer](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurer)** [1..1]: Reference([Organization](/Organization)) Coverage issuer - **[CoverageEligibilityResponse.insurance](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance)** [0..*]: [BackboneElement](/BackboneElement) Patient insurance information - **[CoverageEligibilityResponse.insurance.coverage](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.coverage)** [1..1]: Reference([Coverage](/Coverage)) Insurance information - **[CoverageEligibilityResponse.insurance.inforce](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.inforce)** [0..1]: [boolean](/boolean) Coverage inforce indicator - **[CoverageEligibilityResponse.insurance.benefitPeriod](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.benefitPeriod)** [0..1]: [Period](/Period) When the benefits are applicable - **[CoverageEligibilityResponse.insurance.item](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item)** [0..*]: [BackboneElement](/BackboneElement) Benefits and authorization details - **[CoverageEligibilityResponse.insurance.item.category](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification - **[CoverageEligibilityResponse.insurance.item.productOrService](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[CoverageEligibilityResponse.insurance.item.modifier](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Product or service billing modifiers - **[CoverageEligibilityResponse.insurance.item.provider](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.provider)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole)](/PractitionerRole)) Performing practitioner - **[CoverageEligibilityResponse.insurance.item.excluded](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.excluded)** [0..1]: [boolean](/boolean) Excluded from the plan - **[CoverageEligibilityResponse.insurance.item.name](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.name)** [0..1]: [string](/string) Short name for the benefit - **[CoverageEligibilityResponse.insurance.item.description](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.description)** [0..1]: [markdown](/markdown) Description of the benefit or services covered - **[CoverageEligibilityResponse.insurance.item.network](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.network)** [0..1]: [CodeableConcept](/CodeableConcept) example:[benefit-network](/valueset-benefit-network) In or out of network - **[CoverageEligibilityResponse.insurance.item.unit](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.unit)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[benefit-unit](/valueset-benefit-unit) Individual or family - **[CoverageEligibilityResponse.insurance.item.term](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.term)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[benefit-term](/valueset-benefit-term) Annual or lifetime - **[CoverageEligibilityResponse.insurance.item.benefit](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.benefit)** [0..*]: [BackboneElement](/BackboneElement) Benefit Summary - **[CoverageEligibilityResponse.insurance.item.benefit.type](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.benefit.type)** [1..1]: [CodeableConcept](/CodeableConcept) preferred:[benefit-type](/valueset-benefit-type) Benefit classification - **[CoverageEligibilityResponse.insurance.item.benefit.allowed[x]](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.benefit.allowed%5Bx%5D)** [0..1]: [unsignedInt](/unsignedInt), [string](/string), [Money](/Money) Benefits allowed - **[CoverageEligibilityResponse.insurance.item.benefit.used[x]](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.benefit.used%5Bx%5D)** [0..1]: [unsignedInt](/unsignedInt), [string](/string), [Money](/Money) Benefits used - **[CoverageEligibilityResponse.insurance.item.authorizationRequired](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.authorizationRequired)** [0..1]: [boolean](/boolean) Authorization required flag - **[CoverageEligibilityResponse.insurance.item.authorizationSupporting](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.authorizationSupporting)** [0..*]: [CodeableConcept](/CodeableConcept) example:[coverageeligibilityresponse-ex-auth-support](/valueset-coverageeligibilityresponse-ex-auth-support) Type of required supporting materials - **[CoverageEligibilityResponse.insurance.item.authorizationUrl](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.insurance.item.authorizationUrl)** [0..1]: [uri](/uri) Preauthorization requirements endpoint - **[CoverageEligibilityResponse.preAuthRef](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.preAuthRef)** [0..1]: [string](/string) Preauthorization reference - **[CoverageEligibilityResponse.form](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.form)** [0..1]: [CodeableConcept](/CodeableConcept) example:[forms](/valueset-forms) Printed form identifier - **[CoverageEligibilityResponse.error](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.error)** [0..*]: [BackboneElement](/BackboneElement) Processing errors - **[CoverageEligibilityResponse.error.code](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.error.code)** [1..1]: [CodeableConcept](/CodeableConcept) example:[adjudication-error](/valueset-adjudication-error) Error code detailing processing issues - **[CoverageEligibilityResponse.error.expression](/coverageeligibilityresponse-definitions#CoverageEligibilityResponse.error.expression)** [0..*]: [string](/string) FHIRPath of element(s) related to issue ## Mappings - [CoverageEligibilityResponse Mappings](/coverageeligibilityresponse-mappings) — 24 mapping entries ## Resource Packs ### list-CoverageEligibilityResponse-packs.xml ```xml ``` ## Search Parameters - [created](/coverageeligibilityresponse-search#created) — **date** — The creation date — `CoverageEligibilityResponse.created` - [disposition](/coverageeligibilityresponse-search#disposition) — **string** — The contents of the disposition message — `CoverageEligibilityResponse.disposition` - [identifier](/coverageeligibilityresponse-search#identifier) — **token** — The business identifier — `CoverageEligibilityResponse.identifier` - [insurer](/coverageeligibilityresponse-search#insurer) — **reference** — The organization which generated this resource — `CoverageEligibilityResponse.insurer` - [outcome](/coverageeligibilityresponse-search#outcome) — **token** — The processing outcome — `CoverageEligibilityResponse.outcome` - [patient](/coverageeligibilityresponse-search#patient) — **reference** — The reference to the patient — `CoverageEligibilityResponse.patient` - [request](/coverageeligibilityresponse-search#request) — **reference** — The EligibilityRequest reference — `CoverageEligibilityResponse.request` - [requestor](/coverageeligibilityresponse-search#requestor) — **reference** — The EligibilityRequest provider — `CoverageEligibilityResponse.requestor` - [status](/coverageeligibilityresponse-search#status) — **token** — The EligibilityRequest status — `CoverageEligibilityResponse.status` [Full Search Parameters](/coverageeligibilityresponse-search) ## Examples - [coverageeligibilityresponse-example](/coverageeligibilityresponse-example-coverageeligibilityresponse-example) — coverageeligibilityresponse-example - [coverageeligibilityresponse-example-benefits](/coverageeligibilityresponse-example-coverageeligibilityresponse-example-benefits) — coverageeligibilityresponse-example-benefits - [coverageeligibilityresponse-example-benefits-2](/coverageeligibilityresponse-example-coverageeligibilityresponse-example-benefits-2) — coverageeligibilityresponse-example-benefits-2 - [coverageeligibilityresponse-example-error](/coverageeligibilityresponse-example-coverageeligibilityresponse-example-error) — coverageeligibilityresponse-example-error - [coverageeligibilityresponse-examples-header](/coverageeligibilityresponse-example-coverageeligibilityresponse-examples-header) — coverageeligibilityresponse-examples-header - [E2500](/coverageeligibilityresponse-example-E2500) — coverageeligibilityresponse-example — General Person Primary Coverage Example - [E2501](/coverageeligibilityresponse-example-E2501) — coverageeligibilityresponse-example-benefits — General Person Primary Coverage with Benefit Details - [E2502](/coverageeligibilityresponse-example-E2502) — coverageeligibilityresponse-example-benefits-2 — General Person Primary Coverage with Benefit Details and new insurance - [E2503](/coverageeligibilityresponse-example-E2503) — coverageeligibilityresponse-example-error — General Person Primary Coverage with error [Full Examples](/coverageeligibilityresponse-examples) ## Mapping Exceptions ### coverageeligibilityresponse-event-mapping-exceptions.xml ### Divergent Elements - **Event.identifier** → **CoverageEligibilityResponse.identifier** - summary | reason=Unknown | pattern=true - shortUnmatched | reason=Unknown | pattern=Business identifier for coverage eligibility response | resource=Business Identifier for coverage eligiblity request - definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this coverage eligibility response by the performer 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=Note: This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). 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 response 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. - **Event.basedOn** → **CoverageEligibilityResponse.request** - missingTypes | reason=Unknown | pattern=Reference(Request) - extraTypes | reason=Unknown - shortUnmatched | reason=Unknown | pattern=Fulfills plan, proposal or order | resource=Eligibility request reference - definitionUnmatched | reason=Unknown | pattern=A plan, proposal or order that is fulfilled in whole or in part by this coverage eligibility response. | resource=Reference to the original request resource. - requirementsUnmatched | reason=Unknown | pattern=Allows tracing of authorization for the coverage eligibility response and tracking whether proposals/recommendations were acted upon. | resource=Needed to allow the response to be linked to the request. - **Event.status** → **CoverageEligibilityResponse.status** - shortUnmatched | reason=Unknown | pattern=preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown | resource=active | cancelled | draft | entered-in-error - definitionUnmatched | reason=Unknown | pattern=The current state of the coverage eligibility response. | resource=The status of the resource instance. - commentsUnmatched | reason=Unknown | pattern=A nominal state-transition diagram can be found in the (Event pattern 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. | resource=This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. - **Event.subject** → **CoverageEligibilityResponse.patient** - missingTypes | reason=Unknown | pattern=Reference(Group) - shortUnmatched | reason=Unknown | pattern=Individual service was done for/to | resource=Intended recipient of products and services - definitionUnmatched | reason=Unknown | pattern=The individual or set of individuals the action is being or was performed on. | resource=The party who is the beneficiary of the supplied coverage and for whom eligibility is sought. - requirementsUnmatched | reason=Unknown | pattern=Links the coverage eligibility response to the Patient context. May also affect access control. | resource=Required to provide context and coverage validation. - **Event.note** → **CoverageEligibilityResponse.disposition** - missingTypes | reason=Unknown | pattern=Annotation - extraTypes | reason=Unknown - shortUnmatched | reason=Unknown | pattern=Comments made about the event | resource=Disposition Message - definitionUnmatched | reason=Unknown | pattern=Comments made about the coverage eligibility response by the performer, subject or other participants. | resource=A human readable description of the status of the adjudication. ### Unmapped Elements - **Event.partOf** — Unknown - **Event.reported** — Unknown - **Event.reason** — Unknown - **Event.relevantHistory** — Unknown - **Event.code** — Unknown - **Event.location** — Unknown - **Event.statusReason** — Unknown - **Event.performer.actor** — Unknown - **Event.performer.function** — Unknown - **Event.category** — Unknown - **Event.encounter** — Unknown - **Event.recorded** — Unknown - **Event.occurrence** — Unknown - **Event.product** — Unknown - **Event.performer** — Unknown - **Event.researchStudy** — Unknown ### coverageeligibilityresponse-fivews-mapping-exceptions.xml ### Unmapped Elements - **FiveWs.what** — Unknown - **FiveWs.author** — Unknown - **FiveWs.actor** — Unknown - **FiveWs.cause** — Unknown - **FiveWs.version** — Unknown - **FiveWs.witness** — Unknown - **FiveWs.where** — Unknown - **FiveWs.context** — Unknown - **FiveWs.init** — Unknown - **FiveWs.who** — Unknown - **FiveWs.grade** — Unknown - **FiveWs.planned** — Unknown