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Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Patient, Practitioner

Подробное описание элементов ресурса CoverageEligibilityRequest.

CoverageEligibilityRequest
Element IdCoverageEligibilityRequest
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.

Control0..*
TypeDomainResource
CoverageEligibilityRequest.identifier
Element IdCoverageEligibilityRequest.identifier
Definition

A unique identifier assigned to this coverage eligiblity request.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows coverage eligibility requests to be distinguished and referenced.

CoverageEligibilityRequest.status
Element IdCoverageEligibilityRequest.status
Definition

The status of the resource instance.

Control1..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue (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)
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'.

Summarytrue
Comments

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

CoverageEligibilityRequest.priority
Element IdCoverageEligibilityRequest.priority
Definition

When the requestor expects the processor to complete processing.

Control0..1
Terminology BindingProcess Priority Codes (Example)
TypeCodeableConcept
Requirements

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

CoverageEligibilityRequest.purpose
Element IdCoverageEligibilityRequest.purpose
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.

Control1..*
Terminology BindingEligibilityRequestPurpose (Required)
Typecode
Requirements

To indicate the processing actions requested.

Summarytrue
CoverageEligibilityRequest.patient
Element IdCoverageEligibilityRequest.patient
Definition

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

Control1..1
TypeReference(Patient)
Requirements

Required to provide context and coverage validation.

Summarytrue
Comments

1..1.

CoverageEligibilityRequest.serviced[x]
Element IdCoverageEligibilityRequest.serviced[x]
Definition

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

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required to provide time context for the request.

CoverageEligibilityRequest.created
Element IdCoverageEligibilityRequest.created
Definition

The date when this resource was created.

Control1..1
TypedateTime
Requirements

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

Summarytrue
CoverageEligibilityRequest.enterer
Element IdCoverageEligibilityRequest.enterer
Definition

Person who created the request.

Control0..1
TypeReference(Practitioner | PractitionerRole)
Requirements

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

CoverageEligibilityRequest.provider
Element IdCoverageEligibilityRequest.provider
Definition

The provider which is responsible for the request.

Control0..1
TypeReference(Practitioner | PractitionerRole | Organization)
Requirements

Needed to identify the requestor.

Comments

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.

CoverageEligibilityRequest.insurer
Element IdCoverageEligibilityRequest.insurer
Definition

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

Control1..1
TypeReference(Organization)
Requirements

Need to identify the recipient.

Summarytrue
CoverageEligibilityRequest.facility
Element IdCoverageEligibilityRequest.facility
Definition

Facility where the services are intended to be provided.

Control0..1
TypeReference(Location)
Requirements

Insurance adjudication can be dependant on where services were delivered.

CoverageEligibilityRequest.supportingInfo
Element IdCoverageEligibilityRequest.supportingInfo
Definition

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

Control0..*
Requirements

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

Comments

Often there are multiple jurisdiction specific valuesets which are required.

CoverageEligibilityRequest.supportingInfo.sequence
Element IdCoverageEligibilityRequest.supportingInfo.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

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

CoverageEligibilityRequest.supportingInfo.information
Element IdCoverageEligibilityRequest.supportingInfo.information
Definition

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

Control1..1
TypeReference(Any)
Requirements

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

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.

CoverageEligibilityRequest.supportingInfo.appliesToAll
Element IdCoverageEligibilityRequest.supportingInfo.appliesToAll
Definition

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

Control0..1
Typeboolean
Requirements

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

CoverageEligibilityRequest.insurance
Element IdCoverageEligibilityRequest.insurance
Definition

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

Control0..*
Requirements

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

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.

CoverageEligibilityRequest.insurance.focal
Element IdCoverageEligibilityRequest.insurance.focal
Definition

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

Control0..1
Typeboolean
Requirements

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

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.

CoverageEligibilityRequest.insurance.coverage
Element IdCoverageEligibilityRequest.insurance.coverage
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.

Control1..1
TypeReference(Coverage)
Requirements

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

CoverageEligibilityRequest.insurance.businessArrangement
Element IdCoverageEligibilityRequest.insurance.businessArrangement
Definition

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

Control0..1
Typestring
Requirements

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

CoverageEligibilityRequest.item
Element IdCoverageEligibilityRequest.item
Definition

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

Control0..*
Requirements

The items to be processed for the request.

CoverageEligibilityRequest.item.supportingInfoSequence
Element IdCoverageEligibilityRequest.item.supportingInfoSequence
Definition

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

Control0..*
TypepositiveInt
Requirements

Needed to support or inform the consideration for eligibility.

CoverageEligibilityRequest.item.category
Element IdCoverageEligibilityRequest.item.category
Definition

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

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

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

Comments

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

CoverageEligibilityRequest.item.productOrService
Element IdCoverageEligibilityRequest.item.productOrService
Definition

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

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

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

Comments

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

CoverageEligibilityRequest.item.modifier
Element IdCoverageEligibilityRequest.item.modifier
Definition

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

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

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

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.

CoverageEligibilityRequest.item.provider
Element IdCoverageEligibilityRequest.item.provider
Definition

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

Control0..1
TypeReference(Practitioner | PractitionerRole)
Requirements

Needed to support the evaluation of the eligibility.

CoverageEligibilityRequest.item.quantity
Element IdCoverageEligibilityRequest.item.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
Requirements

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

CoverageEligibilityRequest.item.unitPrice
Element IdCoverageEligibilityRequest.item.unitPrice
Definition

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

Control0..1
TypeMoney
Requirements

Needed to support the evaluation of the eligibility.

CoverageEligibilityRequest.item.facility
Element IdCoverageEligibilityRequest.item.facility
Definition

Facility where the services will be provided.

Control0..1
TypeReference(Location | Organization)
Requirements

Needed to support the evaluation of the eligibility.

CoverageEligibilityRequest.item.diagnosis
Element IdCoverageEligibilityRequest.item.diagnosis
Definition

Patient diagnosis for which care is sought.

Control0..*
Requirements

Needed to support the evaluation of the eligibility.

CoverageEligibilityRequest.item.diagnosis.diagnosis[x]
Element IdCoverageEligibilityRequest.item.diagnosis.diagnosis[x]
Definition

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

Control0..1
Terminology BindingICD-10 Codes (Example)
TypeCodeableConcept|Reference(Condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

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

CoverageEligibilityRequest.item.detail
Element IdCoverageEligibilityRequest.item.detail
Definition

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

Control0..*
TypeReference(Any)
Requirements

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