type: resource-definitionsresource: CoverageEligibilityResponse

CoverageEligibilityResponse Definitions

CoverageEligibilityResponse

CoverageEligibilityResponse resource

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

Cardinality: 0..*

Mappings: workflow=Event; w5=financial.support

CoverageEligibilityResponse.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=Event.identifier; w5=FiveWs.identifier

CoverageEligibilityResponse.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=Event.status; w5=FiveWs.status

CoverageEligibilityResponse.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

CoverageEligibilityResponse.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:eligibilityresponse-purpose

Summary: true

Mappings: w5=FiveWs.class

CoverageEligibilityResponse.patient

Intended recipient of products and services

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

Requirements: Required to provide context and coverage validation.

Cardinality: 1..1

Type: Reference(Patient)

Summary: true

Mappings: workflow=Event.subject; w5=FiveWs.subject; cdanetv4=C06,C07,C08, C05, C04

CoverageEligibilityResponse.event

Event information

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

Cardinality: 0..*

Type: BackboneElement

CoverageEligibilityResponse.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: preferred:datestype

CoverageEligibilityResponse.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

CoverageEligibilityResponse.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]; cdanetv4=F09

CoverageEligibilityResponse.created

Response creation date

Definition: The date 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: w5=FiveWs.recorded

CoverageEligibilityResponse.requestor

Party responsible for the request

Definition: The provider which is responsible for the eligibility, claim, predetermination or preauthorization request.

Comments: This party is responsible for the request but not necessarily professionally responsible for the provision of the individual products and services listed below. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Organization)

Mappings: w5=FiveWs.source; cdanetv4=B01

CoverageEligibilityResponse.request

Eligibility request reference

Definition: Reference to the original request resource.

Requirements: Needed to allow the response to be linked to the request.

Cardinality: 0..1

Type: Reference(CoverageEligibilityRequest)

Summary: true

Mappings: workflow=Event.basedOn; w5=FiveWs.why[x]; cdanetv4=A02|G01

CoverageEligibilityResponse.outcome

queued | complete | error | partial

Definition: The outcome of the request processing.

Comments: 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).

Requirements: To advise the requestor of an overall processing outcome.

Cardinality: 1..1

Type: code

Binding: required:eligibility-outcome

Summary: true

CoverageEligibilityResponse.disposition

Disposition Message

Definition: A human readable description of the status of the adjudication.

Requirements: Provided for user display.

Cardinality: 0..1

Type: string

Mappings: workflow=Event.note

CoverageEligibilityResponse.insurer

Coverage issuer

Definition: The Insurer who issued the coverage in question and is the author of the response.

Requirements: Need to identify the author.

Cardinality: 1..1

Type: Reference(Organization)

Summary: true

CoverageEligibilityResponse.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

CoverageEligibilityResponse.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)

Summary: true

CoverageEligibilityResponse.insurance.inforce

Coverage inforce indicator

Definition: Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.

Requirements: Needed to convey the answer to the eligibility validation request.

Cardinality: 0..1

Type: boolean

CoverageEligibilityResponse.insurance.benefitPeriod

When the benefits are applicable

Definition: The term of the benefits documented in this response.

Requirements: Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

Cardinality: 0..1

Type: Period

CoverageEligibilityResponse.insurance.item

Benefits and authorization details

Definition: Benefits and optionally current balances, and authorization details by category or service.

Cardinality: 0..*

Type: BackboneElement

Constraints: ces-1 | error | SHALL contain a category or a billcode but not both. | category.exists() xor productOrService.exists()

CoverageEligibilityResponse.insurance.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.

Conditions: ces-1

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

CoverageEligibilityResponse.insurance.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.

Aliases: Drug Code, Bill Code, Service Code

Conditions: ces-1

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

CoverageEligibilityResponse.insurance.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

CoverageEligibilityResponse.insurance.item.provider

Performing practitioner

Definition: The practitioner who is eligible for the provision of the product or service.

Requirements: Needed to convey the eligible provider.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole)

Mappings: w5=FiveWs.source; cdanetv4=B01

CoverageEligibilityResponse.insurance.item.excluded

Excluded from the plan

Definition: True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

Requirements: Needed to identify items that are specifically excluded from the coverage.

Cardinality: 0..1

Type: boolean

CoverageEligibilityResponse.insurance.item.name

Short name for the benefit

Definition: A short name or tag for the benefit.

Comments: For example: MED01, or DENT2.

Requirements: Required to align with other plan names.

Cardinality: 0..1

Type: string

CoverageEligibilityResponse.insurance.item.description

Description of the benefit or services covered

Definition: A richer description of the benefit or services covered.

Comments: For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

Requirements: Needed for human readable reference.

Cardinality: 0..1

Type: markdown

CoverageEligibilityResponse.insurance.item.network

In or out of network

Definition: Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Requirements: Needed as in or out of network providers are treated differently under the coverage.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:benefit-network

CoverageEligibilityResponse.insurance.item.unit

Individual or family

Definition: Indicates if the benefits apply to an individual or to the family.

Requirements: Needed for the understanding of the benefits.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:benefit-unit

CoverageEligibilityResponse.insurance.item.term

Annual or lifetime

Definition: The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Requirements: Needed for the understanding of the benefits.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:benefit-term

CoverageEligibilityResponse.insurance.item.benefit

Benefit Summary

Definition: Benefits used to date.

Cardinality: 0..*

Type: BackboneElement

CoverageEligibilityResponse.insurance.item.benefit.type

Benefit classification

Definition: Classification of benefit being provided.

Comments: For example: deductible, visits, benefit amount.

Requirements: Needed to convey the nature of the benefit.

Cardinality: 1..1

Type: CodeableConcept

Binding: preferred:benefit-type

CoverageEligibilityResponse.insurance.item.benefit.allowed[x]

Benefits allowed

Definition: The quantity of the benefit which is permitted under the coverage.

Requirements: Needed to convey the benefits offered under the coverage.

Cardinality: 0..1

Type: unsignedInt, string, Money

CoverageEligibilityResponse.insurance.item.benefit.used[x]

Benefits used

Definition: The quantity of the benefit which have been consumed to date.

Requirements: Needed to convey the benefits consumed to date.

Cardinality: 0..1

Type: unsignedInt, string, Money

CoverageEligibilityResponse.insurance.item.authorizationRequired

Authorization required flag

Definition: A boolean flag indicating whether a preauthorization is required prior to actual service delivery.

Requirements: Needed to convey that preauthorization is required.

Cardinality: 0..1

Type: boolean

CoverageEligibilityResponse.insurance.item.authorizationSupporting

Type of required supporting materials

Definition: Codes or comments regarding information or actions associated with the preauthorization.

Requirements: Needed to inform the provider of collateral materials or actions needed for preauthorization.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:coverageeligibilityresponse-ex-auth-support

CoverageEligibilityResponse.insurance.item.authorizationUrl

Preauthorization requirements endpoint

Definition: A web location for obtaining requirements or descriptive information regarding the preauthorization.

Requirements: Needed to enable insurers to advise providers of informative information.

Cardinality: 0..1

Type: uri

CoverageEligibilityResponse.preAuthRef

Preauthorization reference

Definition: A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.

Requirements: To provide any preauthorization reference for provider use.

Cardinality: 0..1

Type: string

Mappings: cdanetv4=F03; rim=23

CoverageEligibilityResponse.form

Printed form identifier

Definition: A code for the form to be used for printing the content.

Comments: May be needed to identify specific jurisdictional forms.

Requirements: Needed to specify the specific form used for producing output for this response.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:forms

Mappings: cdanetv4=G42

CoverageEligibilityResponse.error

Processing errors

Definition: Errors encountered during the processing of the request.

Requirements: Need to communicate processing issues to the requestor.

Cardinality: 0..*

Type: BackboneElement

CoverageEligibilityResponse.error.code

Error code detailing processing issues

Definition: An error code,from a specified code system, which details why the eligibility check could not be performed.

Requirements: Required to convey processing errors.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:adjudication-error

Summary: true

CoverageEligibilityResponse.error.expression

FHIRPath of element(s) related to issue

Definition: A simple subset of FHIRPath limited to element names, repetition indicators and the default child accessor that identifies one of the elements in the resource that caused this issue to be raised.

Comments: The root of the FHIRPath is the resource or bundle that generated OperationOutcome. Each FHIRPath SHALL resolve to a single node.

Requirements: Allows systems to highlight or otherwise guide users to elements implicated in issues to allow them to be fixed more easily.

Cardinality: 0..*

Type: string

Summary: true