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

Detailed Descriptions for the elements in the CoverageEligibilityResponse resource.

CoverageEligibilityResponse
Element IdCoverageEligibilityResponse
Definition

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

Control1..1
CoverageEligibilityResponse.identifier
Element IdCoverageEligibilityResponse.identifier
Definition

The Response business identifier.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
CoverageEligibilityResponse.status
Element IdCoverageEligibilityResponse.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)
Summarytrue
Comments

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

CoverageEligibilityResponse.purpose
Element IdCoverageEligibilityResponse.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 BindingEligibilityResponsePurpose (Required)
Typecode
Summarytrue
CoverageEligibilityResponse.patient
Element IdCoverageEligibilityResponse.patient
Definition

Patient Resource.

Control0..1
TypeReference(Patient)
CoverageEligibilityResponse.serviced[x]
Element IdCoverageEligibilityResponse.serviced[x]
Definition

The date or dates when the enclosed suite of services are proposed and for which coverage details are requested.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
CoverageEligibilityResponse.created
Element IdCoverageEligibilityResponse.created
Definition

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

Control0..1
TypedateTime
CoverageEligibilityResponse.requestProvider
Element IdCoverageEligibilityResponse.requestProvider
Definition

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

Control0..1
TypeReference(Practitioner | PractitionerRole | Organization)
CoverageEligibilityResponse.request
Element IdCoverageEligibilityResponse.request
Definition

Original request resource reference.

Control0..1
TypeReference(CoverageEligibilityRequest)
CoverageEligibilityResponse.outcome
Element IdCoverageEligibilityResponse.outcome
Definition

Transaction status: error, complete.

Control0..1
Terminology BindingRemittanceOutcome (Required)
Typecode
CoverageEligibilityResponse.disposition
Element IdCoverageEligibilityResponse.disposition
Definition

A description of the status of the adjudication.

Control0..1
Typestring
CoverageEligibilityResponse.insurer
Element IdCoverageEligibilityResponse.insurer
Definition

The Insurer who produced this adjudicated response.

Control0..1
TypeReference(Organization)
CoverageEligibilityResponse.insurance
Element IdCoverageEligibilityResponse.insurance
Definition

The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer.

Control0..*
CoverageEligibilityResponse.insurance.coverage
Element IdCoverageEligibilityResponse.insurance.coverage
Definition

A suite of updated or additional Coverages from the Insurer.

Control0..1
TypeReference(Coverage)
CoverageEligibilityResponse.insurance.contract
Element IdCoverageEligibilityResponse.insurance.contract
Definition

The contract resource which may provide more detailed information.

Control0..1
TypeReference(Contract)
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
CoverageEligibilityResponse.insurance.item
Element IdCoverageEligibilityResponse.insurance.item
Definition

Benefits and optionally current balances by Category or Service.

Control0..*
InvariantsDefined on this element
  • Rule ces-1: SHALL contain a category or a billcode but not both. (expression : category.exists() xor billcode.exists(), xpath: exists(f:category) or exists(f:billcode))
  • Rule ces-2: SHALL contain a billcode for modifier to be present. (expression : modifier.exists() and billcode.exists(), xpath: exists(f:modifier) and exists(f:billcode))
CoverageEligibilityResponse.insurance.item.category
Element IdCoverageEligibilityResponse.insurance.item.category
Definition

High-level Dental, Vision, Medical, Pharmacy, Rehab etc. and detailed types of services: Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
CoverageEligibilityResponse.insurance.item.billcode
Element IdCoverageEligibilityResponse.insurance.item.billcode
Definition

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

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
CoverageEligibilityResponse.insurance.item.modifier
Element IdCoverageEligibilityResponse.insurance.item.modifier
Definition

Item typification or modifiers codes, eg 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
CoverageEligibilityResponse.insurance.item.provider
Element IdCoverageEligibilityResponse.insurance.item.provider
Definition

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

Control0..1
TypeReference(Practitioner | PractitionerRole)
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 indicated the service is included in the coverage.

Control0..1
Typeboolean
CoverageEligibilityResponse.insurance.item.name
Element IdCoverageEligibilityResponse.insurance.item.name
Definition

A short name or tag for the benefit, for example MED01, or DENT2.

Control0..1
Typestring
CoverageEligibilityResponse.insurance.item.description
Element IdCoverageEligibilityResponse.insurance.item.description
Definition

A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

Control0..1
Typestring
CoverageEligibilityResponse.insurance.item.network
Element IdCoverageEligibilityResponse.insurance.item.network
Definition

Network designation.

Control0..1
Terminology BindingNetwork Type Codes (Example)
TypeCodeableConcept
CoverageEligibilityResponse.insurance.item.unit
Element IdCoverageEligibilityResponse.insurance.item.unit
Definition

Unit designation: individual or family.

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

Deductible, visits, benefit amount.

Control1..1
Terminology BindingBenefit Type Codes (Example)
TypeCodeableConcept
CoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Element IdCoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Definition

Benefits allowed.

Control0..1
TypeunsignedInt|string|Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
CoverageEligibilityResponse.insurance.item.benefit.used[x]
Element IdCoverageEligibilityResponse.insurance.item.benefit.used[x]
Definition

Benefits used.

Control0..1
TypeunsignedInt|Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
CoverageEligibilityResponse.insurance.item.authorizationRequired
Element IdCoverageEligibilityResponse.insurance.item.authorizationRequired
Definition

A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service delivery.

Control0..1
Typeboolean
CoverageEligibilityResponse.insurance.item.authorizationSupporting
Element IdCoverageEligibilityResponse.insurance.item.authorizationSupporting
Definition

Codes or comments regarding information or actions assciated with the pre-authorization.

Control0..*
TypeCodeableConcept
CoverageEligibilityResponse.insurance.item.authorizationUrl
Element IdCoverageEligibilityResponse.insurance.item.authorizationUrl
Definition

A descriptive document location.

Control0..1
Typeuri
CoverageEligibilityResponse.preAuthRef
Element IdCoverageEligibilityResponse.preAuthRef
Definition

A reference from the Insurer to which these services pertain.

Control0..1
Typestring
Requirements

To provide any pre-determination or prior authorization reference.

CoverageEligibilityResponse.form
Element IdCoverageEligibilityResponse.form
Definition

The form to be used for printing the content.

Control0..1
Terminology BindingForm Codes (Example)
TypeCodeableConcept
CoverageEligibilityResponse.error
Element IdCoverageEligibilityResponse.error
Definition

Mutually exclusive with Services Provided (Item).

Control0..*
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 BindingAdjudication Error Codes (Example)
TypeCodeableConcept