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

Detailed Descriptions for the elements in the CoverageEligibilityRequest resource.

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.

Control1..1
CoverageEligibilityRequest.identifier
Element IdCoverageEligibilityRequest.identifier
Definition

The Response business identifier.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
CoverageEligibilityRequest.status
Element IdCoverageEligibilityRequest.status
Definition

The status of the resource instance.

Control0..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

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

Summarytrue
CoverageEligibilityRequest.priority
Element IdCoverageEligibilityRequest.priority
Definition

Immediate (STAT), best effort (NORMAL), deferred (DEFER).

Control0..1
Terminology BindingProcess Priority Codes (Example)
TypeCodeableConcept
CoverageEligibilityRequest.purpose
Element IdCoverageEligibilityRequest.purpose
Definition

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 th 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
Summarytrue
CoverageEligibilityRequest.patient
Element IdCoverageEligibilityRequest.patient
Definition

Patient Resource.

Control0..1
TypeReference(Patient)
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]
CoverageEligibilityRequest.created
Element IdCoverageEligibilityRequest.created
Definition

The date when this resource was created.

Control0..1
TypedateTime
CoverageEligibilityRequest.enterer
Element IdCoverageEligibilityRequest.enterer
Definition

Person who created the invoice/claim/pre-determination or pre-authorization.

Control0..1
TypeReference(Practitioner | PractitionerRole)
CoverageEligibilityRequest.provider
Element IdCoverageEligibilityRequest.provider
Definition

The provider who is responsible for the services rendered to the patient.

Control0..1
TypeReference(Practitioner | PractitionerRole | Organization)
CoverageEligibilityRequest.insurer
Element IdCoverageEligibilityRequest.insurer
Definition

The Insurer who is target of the request.

Control0..1
TypeReference(Organization)
CoverageEligibilityRequest.facility
Element IdCoverageEligibilityRequest.facility
Definition

Facility where the services were provided.

Control0..1
TypeReference(Location)
CoverageEligibilityRequest.supportingInformation
Element IdCoverageEligibilityRequest.supportingInformation
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.

Control0..*
Requirements

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

CoverageEligibilityRequest.supportingInformation.sequence
Element IdCoverageEligibilityRequest.supportingInformation.sequence
Definition

Sequence of the information element which serves to provide a link.

Control1..1
TypepositiveInt
Requirements

To provide a reference link.

CoverageEligibilityRequest.supportingInformation.information
Element IdCoverageEligibilityRequest.supportingInformation.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)
CoverageEligibilityRequest.supportingInformation.appliesToAll
Element IdCoverageEligibilityRequest.supportingInformation.appliesToAll
Definition

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

Control0..1
Typeboolean
CoverageEligibilityRequest.insurance
Element IdCoverageEligibilityRequest.insurance
Definition

Insurance policies which the patient has advised may be applicable for paying for health services.

Control0..*
CoverageEligibilityRequest.insurance.focal
Element IdCoverageEligibilityRequest.insurance.focal
Definition

A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

Control0..1
Typeboolean
Requirements

To identify which coverage is being adjudicated.

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

Financial instrument by which payment information for health care.

Control1..1
TypeReference(Coverage)
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

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

The contract number of a business agreement which describes the terms and conditions.

Control0..1
Typestring
CoverageEligibilityRequest.item
Element IdCoverageEligibilityRequest.item
Definition

A list of service types or billable services for which bebefit details and/or an authorization prior to service delivery may be required by the payor.

Control0..*
CoverageEligibilityRequest.item.supportingInformationSequence
Element IdCoverageEligibilityRequest.item.supportingInformationSequence
Definition

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

Control0..*
TypepositiveInt
CoverageEligibilityRequest.item.category
Element IdCoverageEligibilityRequest.item.category
Definition

Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
CoverageEligibilityRequest.item.billcode
Element IdCoverageEligibilityRequest.item.billcode
Definition

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

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
CoverageEligibilityRequest.item.modifier
Element IdCoverageEligibilityRequest.item.modifier
Definition

Item typification or modifiers codes, e.g. for 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.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
CoverageEligibilityRequest.item.provider
Element IdCoverageEligibilityRequest.item.provider
Definition

The practitioner who is responsible for the services rendered to the patient.

Control0..1
TypeReference(Practitioner | PractitionerRole)
CoverageEligibilityRequest.item.quantity
Element IdCoverageEligibilityRequest.item.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
CoverageEligibilityRequest.item.unitPrice
Element IdCoverageEligibilityRequest.item.unitPrice
Definition

The fee for an additional service or product or charge.

Control0..1
TypeMoney
CoverageEligibilityRequest.item.facility
Element IdCoverageEligibilityRequest.item.facility
Definition

Facility where the services were provided.

Control0..1
TypeReference(Location | Organization)
CoverageEligibilityRequest.item.diagnosis
Element IdCoverageEligibilityRequest.item.diagnosis
Definition

List of patient diagnosis for which care is sought.

Control0..*
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]
Element IdCoverageEligibilityRequest.item.diagnosis.diagnosis[x]
Definition

The diagnosis.

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

Required to adjudicate services rendered to condition presented.

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

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

Control0..*
TypeReference(Any)
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.