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13.3 Ресурс CoverageEligibilityResponse - Назначение

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

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

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.

Структура

ИмяФлагиКард.ТипОписание и ограниченияdoco
.. CoverageEligibilityResponse TUDomainResourceCoverageEligibilityResponse resource
Элементы, определённые в прародителе: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for coverage eligiblity request
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
EligibilityResponsePurpose (Required)
... patient Σ1..1Reference(Patient)Intended recipient of products and services
... serviced[x] 0..1Estimated date or dates of service
.... servicedDatedate
.... servicedPeriodPeriod
... created Σ1..1dateTimeResponse creation date
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the request
... request Σ1..1Reference(CoverageEligibilityRequest)Eligibility request reference
... outcome Σ1..1codequeued | complete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer Σ1..1Reference(Organization)Coverage issuer
... insurance 0..*BackboneElementPatient insurance information
.... coverage Σ1..1Reference(Coverage)Insurance information
.... inforce 0..1booleanCoverage inforce indicator
.... benefitPeriod 0..1PeriodWhen the benefits are applicable
.... item I0..*BackboneElementBenefits and authorization details
+ Rule: SHALL contain a category or a billcode but not both.
..... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
..... provider 0..1Reference(Practitioner | PractitionerRole)Performing practitioner
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit or services covered
..... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
..... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
..... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
..... benefit 0..*BackboneElementBenefit Summary
...... type 1..1CodeableConceptBenefit classification
Benefit Type Codes (Example)
...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedStringstring
....... usedMoneyMoney
..... authorizationRequired 0..1booleanAuthorization required flag
..... authorizationSupporting 0..*CodeableConceptType of required supporting materials
..... authorizationUrl 0..1uriPreauthorization requirements endpoint
... preAuthRef 0..1stringPreauthorization reference
... form 0..1CodeableConceptPrinted form identifier
Forms (Example)
... error 0..*BackboneElementProcessing errors
.... code 1..1CodeableConceptError code detailing processing issues
AdjudicationError (Example)

doco Документация по этому формату

UML-диаграмма (Legend)

CoverageEligibilityResponse (DomainResource)A unique identifier assigned to this coverage eligiblity requestidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »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 specifiedpurpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required)EligibilityResponsePurpose! »The party who is the beneficiary of the supplied coverage and for whom eligibility is soughtpatient : Reference [1..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »The date this resource was createdcreated : dateTime [1..1]The provider which is responsible for the requestrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »Reference to the original request resourcerequest : Reference [1..1] « CoverageEligibilityRequest »The outcome of the request processingoutcome : code [1..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A human readable description of the status of the adjudicationdisposition : string [0..1]The Insurer who issued the coverage in question and is the author of the responseinsurer : Reference [1..1] « Organization »A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurredpreAuthRef : string [0..1]A code for the form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Example)Form ?? »InsuranceReference 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 systemcoverage : Reference [1..1] « Coverage »Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service datesinforce : boolean [0..1]The term of the benefits documented in this responsebenefitPeriod : Period [0..1]ItemsCode to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)BenefitCategoryCodes?? »This contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The practitioner who is eligible for the provision of the product or serviceprovider : Reference [0..1] « Practitioner|PractitionerRole »True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefitname : string [0..1]A richer description of the benefit or services covereddescription : string [0..1]Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providersnetwork : CodeableConcept [0..1] « Code to classify in or out of network services. (Strength=Example)NetworkTypeCodes?? »Indicates if the benefits apply to an individual or to the familyunit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. (Strength=Example)BenefitTermCodes?? »A boolean flag indicating whether a preauthorization is required prior to actual service deliveryauthorizationRequired : boolean [0..1]Codes or comments regarding information or actions associated with the preauthorizationauthorizationSupporting : CodeableConcept [0..*]A web location for obtaining requirements or descriptive information regarding the preauthorizationauthorizationUrl : uri [0..1]BenefitClassification of benefit being providedtype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)BenefitTypeCodes?? »The quantity of the benefit which is permitted under the coverageallowed[x] : Type [0..1] « unsignedInt|string|Money »The quantity of the benefit which have been consumed to dateused[x] : Type [0..1] « unsignedInt|string|Money »ErrorsAn error code,from a specified code system, which details why the eligibility check could not be performedcode : CodeableConcept [1..1] « The error codes for adjudication processing. (Strength=Example)Adjudication Error ?? »Benefits used to datebenefit[0..*]Benefits and optionally current balances, and authorization details by category or serviceitem[0..*]Financial instruments for reimbursement for the health care products and servicesinsurance[0..*]Errors encountered during the processing of the requesterror[0..*]

XML-шаблон

<CoverageEligibilityResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation -->
 <patient><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <requestor><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Party responsible for the request --></requestor>
 <request><!-- 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <insurance>  <!-- 0..* Patient insurance information -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
  <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
  <item>  <!-- 0..* Benefits and authorization details -->
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
   <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Performing practitioner --></provider>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <benefit>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Benefit classification --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|string|Money Benefits used --></used[x]>
   </benefit>
   <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag -->
   <authorizationSupporting><!-- 0..* CodeableConcept Type of required supporting materials --></authorizationSupporting>
   <authorizationUrl value="[uri]"/><!-- 0..1 Preauthorization requirements endpoint -->
  </item>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <form><!-- 0..1 CodeableConcept Printed form identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</CoverageEligibilityResponse>

JSON-шаблон

{doco
  "resourceType" : "CoverageEligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "patient" : { Reference(Patient) }, // R!  Intended recipient of products and services
  // serviced[x]: Estimated date or dates of service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // R!  Response creation date
  "requestor" : { Reference(Practitioner|PractitionerRole|Organization) }, // Party responsible for the request
  "request" : { Reference(CoverageEligibilityRequest) }, // R!  Eligibility request reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "insurance" : [{ // Patient insurance information
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "inforce" : <boolean>, // Coverage inforce indicator
    "benefitPeriod" : { Period }, // When the benefits are applicable
    "item" : [{ // Benefits and authorization details
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
      "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "benefit" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Benefit classification
        // allowed[x]: Benefits allowed. One of these 3:
        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 3:
        "usedUnsignedInt" : "<unsignedInt>"
        "usedString" : "<string>"
        "usedMoney" : { Money }
      }],
      "authorizationRequired" : <boolean>, // Authorization required flag
      "authorizationSupporting" : [{ CodeableConcept }], // Type of required supporting materials
      "authorizationUrl" : "<uri>" // Preauthorization requirements endpoint
    }]
  }],
  "preAuthRef" : "<string>", // Preauthorization reference
  "form" : { CodeableConcept }, // Printed form identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle-шаблон

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:CoverageEligibilityResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CoverageEligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityResponse.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityResponse.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityResponse.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityResponse.servicedDate [ date ]
    fhir:CoverageEligibilityResponse.servicedPeriod [ Period ]
  fhir:CoverageEligibilityResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:CoverageEligibilityResponse.requestor [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Party responsible for the request
  fhir:CoverageEligibilityResponse.request [ Reference(CoverageEligibilityRequest) ]; # 1..1 Eligibility request reference
  fhir:CoverageEligibilityResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:CoverageEligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:CoverageEligibilityResponse.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityResponse.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityResponse.insurance.inforce [ boolean ]; # 0..1 Coverage inforce indicator
    fhir:CoverageEligibilityResponse.insurance.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
    fhir:CoverageEligibilityResponse.insurance.item [ # 0..* Benefits and authorization details
      fhir:CoverageEligibilityResponse.insurance.item.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:CoverageEligibilityResponse.insurance.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:CoverageEligibilityResponse.insurance.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
      fhir:CoverageEligibilityResponse.insurance.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Performing practitioner
      fhir:CoverageEligibilityResponse.insurance.item.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:CoverageEligibilityResponse.insurance.item.name [ string ]; # 0..1 Short name for the benefit
      fhir:CoverageEligibilityResponse.insurance.item.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:CoverageEligibilityResponse.insurance.item.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:CoverageEligibilityResponse.insurance.item.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:CoverageEligibilityResponse.insurance.item.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:CoverageEligibilityResponse.insurance.item.benefit [ # 0..* Benefit Summary
        fhir:CoverageEligibilityResponse.insurance.item.benefit.type [ CodeableConcept ]; # 1..1 Benefit classification
        # CoverageEligibilityResponse.insurance.item.benefit.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedMoney [ Money ]
        # CoverageEligibilityResponse.insurance.item.benefit.used[x] : 0..1 Benefits used. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedMoney [ Money ]
      ], ...;
      fhir:CoverageEligibilityResponse.insurance.item.authorizationRequired [ boolean ]; # 0..1 Authorization required flag
      fhir:CoverageEligibilityResponse.insurance.item.authorizationSupporting [ CodeableConcept ], ... ; # 0..* Type of required supporting materials
      fhir:CoverageEligibilityResponse.insurance.item.authorizationUrl [ uri ]; # 0..1 Preauthorization requirements endpoint
    ], ...;
  ], ...;
  fhir:CoverageEligibilityResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:CoverageEligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:CoverageEligibilityResponse.error [ # 0..* Processing errors
    fhir:CoverageEligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since R3

This resource did not exist in Release 2

This analysis is available as XML or JSON.

Структура

ИмяФлагиКард.ТипОписание и ограниченияdoco
.. CoverageEligibilityResponse TUDomainResourceCoverageEligibilityResponse resource
Элементы, определённые в прародителе: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for coverage eligiblity request
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
EligibilityResponsePurpose (Required)
... patient Σ1..1Reference(Patient)Intended recipient of products and services
... serviced[x] 0..1Estimated date or dates of service
.... servicedDatedate
.... servicedPeriodPeriod
... created Σ1..1dateTimeResponse creation date
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the request
... request Σ1..1Reference(CoverageEligibilityRequest)Eligibility request reference
... outcome Σ1..1codequeued | complete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... insurer Σ1..1Reference(Organization)Coverage issuer
... insurance 0..*BackboneElementPatient insurance information
.... coverage Σ1..1Reference(Coverage)Insurance information
.... inforce 0..1booleanCoverage inforce indicator
.... benefitPeriod 0..1PeriodWhen the benefits are applicable
.... item I0..*BackboneElementBenefits and authorization details
+ Rule: SHALL contain a category or a billcode but not both.
..... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
..... provider 0..1Reference(Practitioner | PractitionerRole)Performing practitioner
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit or services covered
..... network 0..1CodeableConceptIn or out of network
Network Type Codes (Example)
..... unit 0..1CodeableConceptIndividual or family
Unit Type Codes (Example)
..... term 0..1CodeableConceptAnnual or lifetime
Benefit Term Codes (Example)
..... benefit 0..*BackboneElementBenefit Summary
...... type 1..1CodeableConceptBenefit classification
Benefit Type Codes (Example)
...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedStringstring
....... usedMoneyMoney
..... authorizationRequired 0..1booleanAuthorization required flag
..... authorizationSupporting 0..*CodeableConceptType of required supporting materials
..... authorizationUrl 0..1uriPreauthorization requirements endpoint
... preAuthRef 0..1stringPreauthorization reference
... form 0..1CodeableConceptPrinted form identifier
Forms (Example)
... error 0..*BackboneElementProcessing errors
.... code 1..1CodeableConceptError code detailing processing issues
AdjudicationError (Example)

doco Документация по этому формату

UML-диаграмма (Legend)

CoverageEligibilityResponse (DomainResource)A unique identifier assigned to this coverage eligiblity requestidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »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 specifiedpurpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required)EligibilityResponsePurpose! »The party who is the beneficiary of the supplied coverage and for whom eligibility is soughtpatient : Reference [1..1] « Patient »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »The date this resource was createdcreated : dateTime [1..1]The provider which is responsible for the requestrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »Reference to the original request resourcerequest : Reference [1..1] « CoverageEligibilityRequest »The outcome of the request processingoutcome : code [1..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A human readable description of the status of the adjudicationdisposition : string [0..1]The Insurer who issued the coverage in question and is the author of the responseinsurer : Reference [1..1] « Organization »A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurredpreAuthRef : string [0..1]A code for the form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Example)Form ?? »InsuranceReference 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 systemcoverage : Reference [1..1] « Coverage »Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service datesinforce : boolean [0..1]The term of the benefits documented in this responsebenefitPeriod : Period [0..1]ItemsCode to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example)BenefitCategoryCodes?? »This contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The practitioner who is eligible for the provision of the product or serviceprovider : Reference [0..1] « Practitioner|PractitionerRole »True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverageexcluded : boolean [0..1]A short name or tag for the benefitname : string [0..1]A richer description of the benefit or services covereddescription : string [0..1]Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providersnetwork : CodeableConcept [0..1] « Code to classify in or out of network services. (Strength=Example)NetworkTypeCodes?? »Indicates if the benefits apply to an individual or to the familyunit : CodeableConcept [0..1] « Unit covered/serviced - individual or family. (Strength=Example)UnitTypeCodes?? »The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'term : CodeableConcept [0..1] « Coverage unit - annual, lifetime. (Strength=Example)BenefitTermCodes?? »A boolean flag indicating whether a preauthorization is required prior to actual service deliveryauthorizationRequired : boolean [0..1]Codes or comments regarding information or actions associated with the preauthorizationauthorizationSupporting : CodeableConcept [0..*]A web location for obtaining requirements or descriptive information regarding the preauthorizationauthorizationUrl : uri [0..1]BenefitClassification of benefit being providedtype : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example)BenefitTypeCodes?? »The quantity of the benefit which is permitted under the coverageallowed[x] : Type [0..1] « unsignedInt|string|Money »The quantity of the benefit which have been consumed to dateused[x] : Type [0..1] « unsignedInt|string|Money »ErrorsAn error code,from a specified code system, which details why the eligibility check could not be performedcode : CodeableConcept [1..1] « The error codes for adjudication processing. (Strength=Example)Adjudication Error ?? »Benefits used to datebenefit[0..*]Benefits and optionally current balances, and authorization details by category or serviceitem[0..*]Financial instruments for reimbursement for the health care products and servicesinsurance[0..*]Errors encountered during the processing of the requesterror[0..*]

XML-шаблон

<CoverageEligibilityResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for coverage eligiblity request --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <purpose value="[code]"/><!-- 1..* auth-requirements | benefits | discovery | validation -->
 <patient><!-- 1..1 Reference(Patient) Intended recipient of products and services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of service --></serviced[x]>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <requestor><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Party responsible for the request --></requestor>
 <request><!-- 1..1 Reference(CoverageEligibilityRequest) Eligibility request reference --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <insurer><!-- 1..1 Reference(Organization) Coverage issuer --></insurer>
 <insurance>  <!-- 0..* Patient insurance information -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->
  <benefitPeriod><!-- 0..1 Period When the benefits are applicable --></benefitPeriod>
  <item>  <!-- 0..* Benefits and authorization details -->
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
   <provider><!-- 0..1 Reference(Practitioner|PractitionerRole) Performing practitioner --></provider>
   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->
   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <benefit>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Benefit classification --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|string|Money Benefits used --></used[x]>
   </benefit>
   <authorizationRequired value="[boolean]"/><!-- 0..1 Authorization required flag -->
   <authorizationSupporting><!-- 0..* CodeableConcept Type of required supporting materials --></authorizationSupporting>
   <authorizationUrl value="[uri]"/><!-- 0..1 Preauthorization requirements endpoint -->
  </item>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <form><!-- 0..1 CodeableConcept Printed form identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</CoverageEligibilityResponse>

JSON-шаблон

{doco
  "resourceType" : "CoverageEligibilityResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for coverage eligiblity request
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "purpose" : ["<code>"], // R!  auth-requirements | benefits | discovery | validation
  "patient" : { Reference(Patient) }, // R!  Intended recipient of products and services
  // serviced[x]: Estimated date or dates of service. One of these 2:
  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // R!  Response creation date
  "requestor" : { Reference(Practitioner|PractitionerRole|Organization) }, // Party responsible for the request
  "request" : { Reference(CoverageEligibilityRequest) }, // R!  Eligibility request reference
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // R!  Coverage issuer
  "insurance" : [{ // Patient insurance information
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "inforce" : <boolean>, // Coverage inforce indicator
    "benefitPeriod" : { Period }, // When the benefits are applicable
    "item" : [{ // Benefits and authorization details
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
      "provider" : { Reference(Practitioner|PractitionerRole) }, // Performing practitioner
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "benefit" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Benefit classification
        // allowed[x]: Benefits allowed. One of these 3:
        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },
        // used[x]: Benefits used. One of these 3:
        "usedUnsignedInt" : "<unsignedInt>"
        "usedString" : "<string>"
        "usedMoney" : { Money }
      }],
      "authorizationRequired" : <boolean>, // Authorization required flag
      "authorizationSupporting" : [{ CodeableConcept }], // Type of required supporting materials
      "authorizationUrl" : "<uri>" // Preauthorization requirements endpoint
    }]
  }],
  "preAuthRef" : "<string>", // Preauthorization reference
  "form" : { CodeableConcept }, // Printed form identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle-шаблон

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:CoverageEligibilityResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CoverageEligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for coverage eligiblity request
  fhir:CoverageEligibilityResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:CoverageEligibilityResponse.purpose [ code ], ... ; # 1..* auth-requirements | benefits | discovery | validation
  fhir:CoverageEligibilityResponse.patient [ Reference(Patient) ]; # 1..1 Intended recipient of products and services
  # CoverageEligibilityResponse.serviced[x] : 0..1 Estimated date or dates of service. One of these 2
    fhir:CoverageEligibilityResponse.servicedDate [ date ]
    fhir:CoverageEligibilityResponse.servicedPeriod [ Period ]
  fhir:CoverageEligibilityResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:CoverageEligibilityResponse.requestor [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Party responsible for the request
  fhir:CoverageEligibilityResponse.request [ Reference(CoverageEligibilityRequest) ]; # 1..1 Eligibility request reference
  fhir:CoverageEligibilityResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:CoverageEligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:CoverageEligibilityResponse.insurer [ Reference(Organization) ]; # 1..1 Coverage issuer
  fhir:CoverageEligibilityResponse.insurance [ # 0..* Patient insurance information
    fhir:CoverageEligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:CoverageEligibilityResponse.insurance.inforce [ boolean ]; # 0..1 Coverage inforce indicator
    fhir:CoverageEligibilityResponse.insurance.benefitPeriod [ Period ]; # 0..1 When the benefits are applicable
    fhir:CoverageEligibilityResponse.insurance.item [ # 0..* Benefits and authorization details
      fhir:CoverageEligibilityResponse.insurance.item.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:CoverageEligibilityResponse.insurance.item.productOrService [ CodeableConcept ]; # 0..1 Billing, service, product, or drug code
      fhir:CoverageEligibilityResponse.insurance.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
      fhir:CoverageEligibilityResponse.insurance.item.provider [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Performing practitioner
      fhir:CoverageEligibilityResponse.insurance.item.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:CoverageEligibilityResponse.insurance.item.name [ string ]; # 0..1 Short name for the benefit
      fhir:CoverageEligibilityResponse.insurance.item.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:CoverageEligibilityResponse.insurance.item.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:CoverageEligibilityResponse.insurance.item.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:CoverageEligibilityResponse.insurance.item.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:CoverageEligibilityResponse.insurance.item.benefit [ # 0..* Benefit Summary
        fhir:CoverageEligibilityResponse.insurance.item.benefit.type [ CodeableConcept ]; # 1..1 Benefit classification
        # CoverageEligibilityResponse.insurance.item.benefit.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.allowedMoney [ Money ]
        # CoverageEligibilityResponse.insurance.item.benefit.used[x] : 0..1 Benefits used. One of these 3
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedUnsignedInt [ unsignedInt ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedString [ string ]
          fhir:CoverageEligibilityResponse.insurance.item.benefit.usedMoney [ Money ]
      ], ...;
      fhir:CoverageEligibilityResponse.insurance.item.authorizationRequired [ boolean ]; # 0..1 Authorization required flag
      fhir:CoverageEligibilityResponse.insurance.item.authorizationSupporting [ CodeableConcept ], ... ; # 0..* Type of required supporting materials
      fhir:CoverageEligibilityResponse.insurance.item.authorizationUrl [ uri ]; # 0..1 Preauthorization requirements endpoint
    ], ...;
  ], ...;
  fhir:CoverageEligibilityResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:CoverageEligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:CoverageEligibilityResponse.error [ # 0..* Processing errors
    fhir:CoverageEligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since Release 3

This resource did not exist in Release 2

This analysis is available as XML or JSON.

 

See the Profiles & Extensions and the Альтернативные определения: Основное определение XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the Анализ зависимостей

PathОписаниеТипСсылка
CoverageEligibilityResponse.status A code specifying the state of the resource instance.RequiredFinancialResourceStatusCodes
CoverageEligibilityResponse.purpose A code specifying the types of information being requested.RequiredEligibilityResponsePurpose
CoverageEligibilityResponse.outcome The outcome of the processing.RequiredRemittanceOutcome
CoverageEligibilityResponse.insurance.item.category Benefit categories such as: oral, medical, vision etc.ExampleBenefitCategoryCodes
CoverageEligibilityResponse.insurance.item.productOrService Allowable service and product codes.ExampleUSCLSCodes
CoverageEligibilityResponse.insurance.item.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifierTypeCodes
CoverageEligibilityResponse.insurance.item.network Code to classify in or out of network services.ExampleNetworkTypeCodes
CoverageEligibilityResponse.insurance.item.unit Unit covered/serviced - individual or family.ExampleUnitTypeCodes
CoverageEligibilityResponse.insurance.item.term Coverage unit - annual, lifetime.ExampleBenefitTermCodes
CoverageEligibilityResponse.insurance.item.benefit.type Deductable, visits, co-pay, etc.ExampleBenefitTypeCodes
CoverageEligibilityResponse.form The forms codes.ExampleForm Codes
CoverageEligibilityResponse.error.code The error codes for adjudication processing.ExampleAdjudication Error Codes

idLevelLocationОпределениеExpression
ces-1Rule CoverageEligibilityResponse.insurance.itemSHALL contain a category or a billcode but not both.category.exists() xor productOrService.exists()

Параметры поиска для этого ресурса. Также к нему применяются общие параметры. Более подробную информацию о поиске в REST, обмене сообщениями и сервисах см. в разделе Поиск.

ИмяТипОпределениеВыражениеIn Common
createddateThe creation dateCoverageEligibilityResponse.created
dispositionstringThe contents of the disposition messageCoverageEligibilityResponse.disposition
identifiertokenThe business identifierCoverageEligibilityResponse.identifier
insurerreferenceThe organization which generated this resourceCoverageEligibilityResponse.insurer
(Organization)
outcometokenThe processing outcomeCoverageEligibilityResponse.outcome
patientreferenceThe reference to the patientCoverageEligibilityResponse.patient
(Patient)
requestreferenceThe EligibilityRequest referenceCoverageEligibilityResponse.request
(CoverageEligibilityRequest)
requestorreferenceThe EligibilityRequest providerCoverageEligibilityResponse.requestor
(Practitioner, Organization, PractitionerRole)
statustokenThe EligibilityRequest statusCoverageEligibilityResponse.status