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

Подробное описание элементов ресурса CoverageEligibilityResponse.

CoverageEligibilityResponse
Element IdCoverageEligibilityResponse
Definition

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

Control0..*
TypeDomainResource
CoverageEligibilityResponse.identifier
Element IdCoverageEligibilityResponse.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.

CoverageEligibilityResponse.status
Element IdCoverageEligibilityResponse.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.

CoverageEligibilityResponse.purpose
Element IdCoverageEligibilityResponse.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 BindingEligibilityResponsePurpose (Required)
Typecode
Requirements

To indicate the processing actions requested.

Summarytrue
CoverageEligibilityResponse.patient
Element IdCoverageEligibilityResponse.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
CoverageEligibilityResponse.serviced[x]
Element IdCoverageEligibilityResponse.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.

CoverageEligibilityResponse.created
Element IdCoverageEligibilityResponse.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Requirements

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

Summarytrue
CoverageEligibilityResponse.requestor
Element IdCoverageEligibilityResponse.requestor
Definition

The provider which is responsible for the request.

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

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

CoverageEligibilityResponse.request
Element IdCoverageEligibilityResponse.request
Definition

Reference to the original request resource.

Control1..1
TypeReference(CoverageEligibilityRequest)
Requirements

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

Summarytrue
CoverageEligibilityResponse.outcome
Element IdCoverageEligibilityResponse.outcome
Definition

The outcome of the request processing.

Control1..1
Terminology BindingRemittanceOutcome (Required)
Typecode
Requirements

To advise the requestor of an overall processing outcome.

Summarytrue
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).

CoverageEligibilityResponse.disposition
Element IdCoverageEligibilityResponse.disposition
Definition

A human readable description of the status of the adjudication.

Control0..1
Typestring
Requirements

Provided for user display.

CoverageEligibilityResponse.insurer
Element IdCoverageEligibilityResponse.insurer
Definition

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

Control1..1
TypeReference(Organization)
Requirements

Need to identify the author.

Summarytrue
CoverageEligibilityResponse.insurance
Element IdCoverageEligibilityResponse.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.

CoverageEligibilityResponse.insurance.coverage
Element IdCoverageEligibilityResponse.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.

Summarytrue
CoverageEligibilityResponse.insurance.inforce
Element IdCoverageEligibilityResponse.insurance.inforce
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.

Control0..1
Typeboolean
Requirements

Needed to convey the answer to the eligibility validation request.

CoverageEligibilityResponse.insurance.benefitPeriod
Element IdCoverageEligibilityResponse.insurance.benefitPeriod
Definition

The term of the benefits documented in this response.

Control0..1
TypePeriod
Requirements

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

CoverageEligibilityResponse.insurance.item
Element IdCoverageEligibilityResponse.insurance.item
Definition

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

Control0..*
Invariants
Defined on this element
ces-1Rule SHALL contain a category or a billcode but not both.category.exists() xor productOrService.exists()
CoverageEligibilityResponse.insurance.item.category
Element IdCoverageEligibilityResponse.insurance.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.

CoverageEligibilityResponse.insurance.item.productOrService
Element IdCoverageEligibilityResponse.insurance.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.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

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

CoverageEligibilityResponse.insurance.item.modifier
Element IdCoverageEligibilityResponse.insurance.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.

CoverageEligibilityResponse.insurance.item.provider
Element IdCoverageEligibilityResponse.insurance.item.provider
Definition

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

Control0..1
TypeReference(Practitioner | PractitionerRole)
Requirements

Needed to convey the eligible provider.

CoverageEligibilityResponse.insurance.item.excluded
Element IdCoverageEligibilityResponse.insurance.item.excluded
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.

Control0..1
Typeboolean
Requirements

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

CoverageEligibilityResponse.insurance.item.name
Element IdCoverageEligibilityResponse.insurance.item.name
Definition

A short name or tag for the benefit.

Control0..1
Typestring
Requirements

Required to align with other plan names.

Comments

For example: MED01, or DENT2.

CoverageEligibilityResponse.insurance.item.description
Element IdCoverageEligibilityResponse.insurance.item.description
Definition

A richer description of the benefit or services covered.

Control0..1
Typestring
Requirements

Needed for human readable reference.

Comments

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

CoverageEligibilityResponse.insurance.item.network
Element IdCoverageEligibilityResponse.insurance.item.network
Definition

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

Control0..1
Terminology BindingNetwork Type Codes (Example)
TypeCodeableConcept
Requirements

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

CoverageEligibilityResponse.insurance.item.unit
Element IdCoverageEligibilityResponse.insurance.item.unit
Definition

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

Control0..1
Terminology BindingUnit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

CoverageEligibilityResponse.insurance.item.term
Element IdCoverageEligibilityResponse.insurance.item.term
Definition

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

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

Needed for the understanding of the benefits.

CoverageEligibilityResponse.insurance.item.benefit
Element IdCoverageEligibilityResponse.insurance.item.benefit
Definition

Benefits used to date.

Control0..*
CoverageEligibilityResponse.insurance.item.benefit.type
Element IdCoverageEligibilityResponse.insurance.item.benefit.type
Definition

Classification of benefit being provided.

Control1..1
Terminology BindingBenefit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the nature of the benefit.

Comments

For example: deductible, visits, benefit amount.

CoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Element IdCoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Definition

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

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

Needed to convey the benefits offered under the coverage.

CoverageEligibilityResponse.insurance.item.benefit.used[x]
Element IdCoverageEligibilityResponse.insurance.item.benefit.used[x]
Definition

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

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

Needed to convey the benefits consumed to date.

CoverageEligibilityResponse.insurance.item.authorizationRequired
Element IdCoverageEligibilityResponse.insurance.item.authorizationRequired
Definition

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

Control0..1
Typeboolean
Requirements

Needed to convey that preauthorization is required.

CoverageEligibilityResponse.insurance.item.authorizationSupporting
Element IdCoverageEligibilityResponse.insurance.item.authorizationSupporting
Definition

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

Control0..*
TypeCodeableConcept
Requirements

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

CoverageEligibilityResponse.insurance.item.authorizationUrl
Element IdCoverageEligibilityResponse.insurance.item.authorizationUrl
Definition

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

Control0..1
Typeuri
Requirements

Needed to enable insurers to advise providers of informative information.

CoverageEligibilityResponse.preAuthRef
Element IdCoverageEligibilityResponse.preAuthRef
Definition

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

Control0..1
Typestring
Requirements

To provide any preauthorization reference for provider use.

CoverageEligibilityResponse.form
Element IdCoverageEligibilityResponse.form
Definition

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

Control0..1
Terminology BindingForms (Example)
TypeCodeableConcept
Requirements

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

Comments

May be needed to identify specific jurisdictional forms.

CoverageEligibilityResponse.error
Element IdCoverageEligibilityResponse.error
Definition

Errors encountered during the processing of the request.

Control0..*
Requirements

Need to communicate processing issues to the requestor.

CoverageEligibilityResponse.error.code
Element IdCoverageEligibilityResponse.error.code
Definition

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

Control1..1
Terminology BindingAdjudicationError (Example)
TypeCodeableConcept
Requirements

Required to convey processing errors.