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EligibilityResponse

Owning committee name

Financial Management

Contributing or Reviewing Work Groups

FHIR Resource Development Project Insight ID

994

Scope of coverage

Represents more or less granular information verifying whether or not a patient is enrolled in a public health program or private health insurance policy for which premiums are to be or have been paid, and for which types or specific healthcare services are covered. It includes verification of coverage for humans as well as animals.

RIM scope

Observation class with classCode of VERIF and moodCode of EVN.

Resource appropriateness

Eligibility Response is a determination by a public health program or private health insurer, or a designate that a specific insurance policy is in effect on a specific date for a specific individual, which is used to verify a patient’s eligibility for health services. It does not imply that a particular service and/or product will be covered and/or paid if submitted to a public health program or private health insurer.

Expected implementations

Referenced by CCDA in situations where coverage has is not yet effective, is effective, or has lapsed.

Content sources

  • v2 IN1, IN2, IN3 segments
  • v3 Eligibility and Coverage models
  • X12 270, 271, 834, 820
  • NCPDP

Example Scenarios

Payor verification of patient’s coverage in response to provider Eligibility query.

Resource Relationships

Eligibility Response is associated to Eligibility, Coverage, Patients as covered parties, and RelatedPersons or Organizations as policy holders. Eligibility Response is referenced by Claim.

Timelines

Part of initial DSTU.

gForge Users

N/A