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ElementAliasesCard.TypeIs ModifierModifier ReasonSummaryBindingExampleDefault ValueMissing MeaningRegexShort NameDefinitionRequirementsCommentsTo Do
CoverageEligibilityResponseDomainResourceCoverageEligibilityResponse resourceThis resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.
!Identification
CoverageEligibilityResponse.identifier0..*IdentifierBusiness Identifier for coverage eligiblity requestA unique identifier assigned to this coverage eligiblity request.Allows coverage eligibility requests to be distinguished and referenced.
CoverageEligibilityResponse.status1..1codeYThis 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 validYEligibilityResponseStatusactive | cancelled | draft | entered-in-errorThe status of the resource instance.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'.This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid
CoverageEligibilityResponse.purpose1..*codeYEligibilityResponsePurposeauth-requirements | benefits | discovery | validationCode 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.To indicate the processing actions requested.
!Patient Information
CoverageEligibilityResponse.patient1..1Reference(Patient)Intended recipient of products and servicesThe party who is the beneficiary of the supplied coverage and for whom eligibility is sought.Required to provide context and coverage validation.
CoverageEligibilityResponse.serviced[x]0..1date|PeriodEstimated date or dates of serviceThe date or dates when the enclosed suite of services were performed or completed.Required to provide time context for the request.
CoverageEligibilityResponse.created1..1dateTimeResponse creation dateThe date this resource was created.Need to record a timestamp for use by both the recipient and the issuer.
CoverageEligibilityResponse.requestor0..1Reference(Practitioner|PractitionerRole|Organization)Party responsible for the requestThe provider which is responsible for the request.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.was requestProvider
CoverageEligibilityResponse.request1..1Reference(CoverageEligibilityRequest)Eligibility request referenceReference to the original request resource.Needed to allow the response to be linked to the request.
CoverageEligibilityResponse.outcome1..1codeRemittanceOutcomequeued | complete | error | partialThe outcome of the request processing.To advise the requestor of an overall processing outcome.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.disposition0..1stringDisposition MessageA human readable description of the status of the adjudication.Provided for user display.
CoverageEligibilityResponse.insurer1..1Reference(Organization)Coverage issuerThe Insurer who issued the coverage in question and is the author of the response.Need to identify the author.
!Insurance Information
CoverageEligibilityResponse.insurance0..*=InsurancePatient insurance informationFinancial instruments for reimbursement for the health care products and services.There must be at least one coverage for which eligibility is requested.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.coverage1..1Reference(Coverage)Insurance informationReference 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.Required to allow the adjudicator to locate the correct policy and history within their information system.
CoverageEligibilityResponse.insurance.contract0..1Reference(Contract)Contract detailsThe contract resource which may provide more detailed information.REMOVE
CoverageEligibilityResponse.insurance.inforce0..1booleanCoverage inforce indicatorFlag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.Needed to convey the answer to the eligibility validation request.
CoverageEligibilityResponse.insurance.benefitPeriod0..1PeriodWhen the benefits are applicableThe term of the benefits documented in this response.Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.
!Plan Balance Information
CoverageEligibilityResponse.insurance.item0..*=ItemsBenefits and authorization detailsBenefits and optionally current balances, and authorization details by category or service.
CoverageEligibilityResponse.insurance.item.category0..1CodeableConceptBenefitCategoryBenefit classification Code to identify the general type of benefits under which products and services are provided.Needed to convey the category of service or product for which eligibility is sought.Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage
CoverageEligibilityResponse.insurance.item.productOrServiceDrug Code; Bill Code; Service Code0..1CodeableConceptServiceProductBilling, service, product, or drug codeThis contains the product, service, drug or other billing code for the item.Needed to convey the actual service or product for which eligibility is sought.Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).
CoverageEligibilityResponse.insurance.item.modifier0..*CodeableConceptModifiersProduct or service billing modifiersItem typification or modifiers codes to convey additional context for the product or service.To support provision of the item or to charge an elevated fee.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.provider0..1Reference(Practitioner|PractitionerRole)Performing practitionerThe practitioner who is eligible for the provision of the product or service.Needed to convey the eligible provider.
CoverageEligibilityResponse.insurance.item.excluded0..1booleanExcluded from the planTrue if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.Needed to identify items that are specifically excluded from the coverage.
CoverageEligibilityResponse.insurance.item.name0..1stringShort name for the benefitA short name or tag for the benefit.Required to align with other plan names.For example: MED01, or DENT2
CoverageEligibilityResponse.insurance.item.description0..1stringDescription of the benefit or services coveredA richer description of the benefit or services covered.Needed for human readable reference.For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'
CoverageEligibilityResponse.insurance.item.network0..1CodeableConceptBenefitNetworkIn or out of networkIs a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.Needed as in or out of network providers are treated differently under the coverage.
CoverageEligibilityResponse.insurance.item.unit0..1CodeableConceptBenefitUnitIndividual or familyIndicates if the benefits apply to an individual or to the family.Needed for the understanding of the benefits.
CoverageEligibilityResponse.insurance.item.term0..1CodeableConceptBenefitTermAnnual or lifetimeThe term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.Needed for the understanding of the benefits.
CoverageEligibilityResponse.insurance.item.benefit0..*=BenefitBenefit SummaryBenefits used to date
CoverageEligibilityResponse.insurance.item.benefit.type1..1CodeableConceptBenefitTypeBenefit typeClassification of benefit being provided.Needed to convey the nature of the benefit.For example: deductible, visits, benefit amount.
CoverageEligibilityResponse.insurance.item.benefit.allowed[x]0..1unsignedInt|string|MoneyBenefits allowedThe quantity of the benefit which is permitted under the coverage.Needed to convey the benefits offered under the coverage.
CoverageEligibilityResponse.insurance.item.benefit.used[x]0..1unsignedInt|MoneyBenefits usedThe quantity of the benefit which have been consumed to date.Needed to convey the benefits consumed to date.
CoverageEligibilityResponse.insurance.item.authorizationRequired0..1booleanAuthorization required flagA boolean flag indicating whether a preauthorization is required prior to actual service delivery.Needed to convey that preauthorization is required.
CoverageEligibilityResponse.insurance.item.authorizationSupporting0..*CodeableConceptType of required supporting materialsCodes or comments regarding information or actions associated with the preauthorization.Needed to inform the provider of collateral materials or actions needed for preauthorization.
CoverageEligibilityResponse.insurance.item.authorizationUrl0..1uriPreauthorization requirements endpointA web location for obtaining requirements or descriptive information regarding the preauthorization.Needed to enable insurers to advise providers of informative information.
CoverageEligibilityResponse.preAuthRef0..1stringPreauthorization referenceA reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.To provide any preauthorization reference for provider use.
CoverageEligibilityResponse.form0..1CodeableConceptFormsPrinted form identifierA code for the form to be used for printing the content.Needed to specify the specific form used for producing output for this response.May be needed to identify specific jurisdictional forms.
!ErrorsProcessing errors
CoverageEligibilityResponse.error0..*=ErrorsProcessing errorsErrors encountered during the processing of the request.Need to communicate processing issues to the requestor.
CoverageEligibilityResponse.error.code1..1CodeableConceptAdjudicationErrorError code detailing processing issuesAn error code,from a specified code system, which details why the eligibility check could not be performed.Required to convey processing errors.