type: resource-definitionsresource: CoverageEligibilityRequest

CoverageEligibilityRequest Definitions

CoverageEligibilityRequest

CoverageEligibilityRequest resource

Definition: 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.

Cardinality: 0..*

Mappings: workflow=Request; w5=financial.support

CoverageEligibilityRequest.identifier

Business Identifier for coverage eligiblity request

Definition: A unique identifier assigned to this coverage eligiblity request.

Requirements: Allows coverage eligibility requests to be distinguished and referenced.

Cardinality: 0..*

Type: Identifier

Mappings: workflow=Request.identifier; w5=FiveWs.identifier

CoverageEligibilityRequest.status

active | cancelled | draft | entered-in-error

Definition: The status of the resource instance.

Comments: This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Requirements: Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Cardinality: 1..1

Type: code

Binding: required:fm-status

Summary: true

Is Modifier: true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Request.status; w5=FiveWs.status

CoverageEligibilityRequest.statusReason

Reason for status change

Definition: Used to indicate why the status has changed.

Comments: Implementation guides may consider adding invariants such that if status = cancelled, statusReason SHALL be supplied.

Requirements: This is used to implement conformance on other elements.

Cardinality: 0..1

Type: string

Summary: true

CoverageEligibilityRequest.priority

Desired processing priority

Definition: When the requestor expects the processor to complete processing.

Requirements: Needed to advise the prossesor on the urgency of the request.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:process-priority

Mappings: workflow=Request.priority; w5=FiveWs.class

CoverageEligibilityRequest.purpose

auth-requirements | benefits | discovery | validation

Definition: 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.

Requirements: To indicate the processing actions requested.

Cardinality: 1..*

Type: code

Binding: required:eligibilityrequest-purpose

Summary: true

Mappings: w5=FiveWs.class

CoverageEligibilityRequest.patient

Intended recipient of products and services

Definition: The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.

Comments: 1..1.

Requirements: Required to provide context and coverage validation.

Cardinality: 1..1

Type: Reference(Patient)

Summary: true

Mappings: workflow=Request.subject; w5=FiveWs.subject

CoverageEligibilityRequest.event

Event information

Definition: Information code for an event with a corresponding date or period.

Cardinality: 0..*

Type: BackboneElement

CoverageEligibilityRequest.event.type

Specific event

Definition: A coded event such as when a service is expected or a card printed.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:datestype

CoverageEligibilityRequest.event.when[x]

Occurance date or period

Definition: A date or period in the past or future indicating when the event occurred or is expectd to occur.

Cardinality: 1..1

Type: dateTime, Period

CoverageEligibilityRequest.serviced[x]

Estimated date or dates of service

Definition: The date or dates when the enclosed suite of services were performed or completed.

Requirements: Required to provide time context for the request.

Cardinality: 0..1

Type: date, Period

Mappings: w5=FiveWs.done[x]

CoverageEligibilityRequest.created

Creation date

Definition: The date when this resource was created.

Requirements: Need to record a timestamp for use by both the recipient and the issuer.

Cardinality: 1..1

Type: dateTime

Summary: true

Mappings: workflow=Request.authoredOn; w5=FiveWs.recorded

CoverageEligibilityRequest.enterer

Author

Definition: Person who created the request.

Requirements: Some jurisdictions require the contact information for personnel completing eligibility requests.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole)

Mappings: w5=FiveWs.author

CoverageEligibilityRequest.provider

Party responsible for the request

Definition: The provider which is responsible for the request.

Comments: Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.

Requirements: Needed to identify the requestor.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Organization)

Mappings: workflow=Request.requester; w5=FiveWs.source

CoverageEligibilityRequest.insurer

Coverage issuer

Definition: The Insurer who issued the coverage in question and is the recipient of the request.

Requirements: Need to identify the recipient.

Cardinality: 1..1

Type: Reference(Organization)

Summary: true

Mappings: workflow=Request.performer; w5=FiveWs.who

CoverageEligibilityRequest.facility

Servicing facility

Definition: Facility where the services are intended to be provided.

Requirements: Insurance adjudication can be dependant on where services were delivered.

Cardinality: 0..1

Type: Reference(Location)

Mappings: w5=FiveWs.where[x]

CoverageEligibilityRequest.supportingInfo

Supporting information

Definition: Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Comments: Often there are multiple jurisdiction specific valuesets which are required.

Requirements: Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Cardinality: 0..*

Type: BackboneElement

CoverageEligibilityRequest.supportingInfo.sequence

Information instance identifier

Definition: A number to uniquely identify supporting information entries.

Requirements: Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Cardinality: 1..1

Type: positiveInt

CoverageEligibilityRequest.supportingInfo.information

Data to be provided

Definition: Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Comments: 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.

Requirements: To convey the data content to be provided when the information is more than a simple code or period.

Cardinality: 1..1

Type: Reference(Resource)

CoverageEligibilityRequest.supportingInfo.appliesToAll

Applies to all items

Definition: The supporting materials are applicable for all detail items, product/servce categories and specific billing codes.

Requirements: Needed to convey that the information is universal to the request.

Cardinality: 0..1

Type: boolean

CoverageEligibilityRequest.insurance

Patient insurance information

Definition: Financial instruments for reimbursement for the health care products and services.

Comments: 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.

Requirements: There must be at least one coverage for which eligibility is requested.

Cardinality: 0..*

Type: BackboneElement

CoverageEligibilityRequest.insurance.focal

Applicable coverage

Definition: A flag to indicate that this Coverage is to be used for evaluation of this request when set to true.

Comments: 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.

Requirements: To identify which coverage in the list is being used to evaluate this request.

Cardinality: 0..1

Type: boolean

CoverageEligibilityRequest.insurance.coverage

Insurance information

Definition: 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.

Requirements: Required to allow the adjudicator to locate the correct policy and history within their information system.

Cardinality: 1..1

Type: Reference(Coverage)

CoverageEligibilityRequest.insurance.businessArrangement

Additional provider contract number

Definition: A business agreement number established between the provider and the insurer for special business processing purposes.

Requirements: Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

Cardinality: 0..1

Type: string

CoverageEligibilityRequest.item

Item to be evaluated for eligibiity

Definition: Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor.

Requirements: The items to be processed for the request.

Cardinality: 0..*

Type: BackboneElement

CoverageEligibilityRequest.item.supportingInfoSequence

Applicable exception or supporting information

Definition: Exceptions, special conditions and supporting information applicable for this service or product line.

Requirements: Needed to support or inform the consideration for eligibility.

Cardinality: 0..*

Type: positiveInt

CoverageEligibilityRequest.item.category

Benefit classification

Definition: Code to identify the general type of benefits under which products and services are provided.

Comments: Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Requirements: Needed to convey the category of service or product for which eligibility is sought.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

CoverageEligibilityRequest.item.productOrService

Billing, service, product, or drug code

Definition: This contains the product, service, drug or other billing code for the item.

Comments: Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).

Requirements: Needed to convey the actual service or product for which eligibility is sought.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

CoverageEligibilityRequest.item.modifier

Product or service billing modifiers

Definition: Item typification or modifiers codes to convey additional context for the product or service.

Comments: 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.

Requirements: To support provision of the item or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

CoverageEligibilityRequest.item.provider

Perfoming practitioner

Definition: The practitioner who is responsible for the product or service to be rendered to the patient.

Requirements: Needed to support the evaluation of the eligibility.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole)

Mappings: workflow=Request.requester; w5=FiveWs.source

CoverageEligibilityRequest.item.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

CoverageEligibilityRequest.item.unitPrice

Fee, charge or cost per item

Definition: The amount charged to the patient by the provider for a single unit.

Requirements: Needed to support the evaluation of the eligibility.

Cardinality: 0..1

Type: Money

CoverageEligibilityRequest.item.facility

Servicing facility

Definition: Facility where the services will be provided.

Requirements: Needed to support the evaluation of the eligibility.

Cardinality: 0..1

Type: Reference(Location, Organization)

CoverageEligibilityRequest.item.diagnosis

Applicable diagnosis

Definition: Patient diagnosis for which care is sought.

Requirements: Needed to support the evaluation of the eligibility.

Cardinality: 0..*

Type: BackboneElement

Mappings: v2=Request.reasonReference

CoverageEligibilityRequest.item.diagnosis.diagnosis[x]

Nature of illness or problem

Definition: The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Requirements: Provides health context for the evaluation of the products and/or services.

Cardinality: 0..1

Type: CodeableConcept, Reference(Condition)

Binding: example:icd-10

CoverageEligibilityRequest.item.detail

Product or service details

Definition: The plan/proposal/order describing the proposed service in detail.

Requirements: Needed to provide complex service proposal such as a Device or a plan.

Cardinality: 0..*

Type: Reference(Resource)