DSTU2 STU 3 Candidate
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R3 R2

7.5.5 Resource EligibilityResponse - Detailed Descriptions Resource EligibilityResponse - Detailed Descriptions Detailed Descriptions for the elements in the EligibilityResponse resource.

Detailed Descriptions for the elements in the EligibilityResponse resource.

EligibilityResponse
Definition

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

Control 1..1
Summary true
EligibilityResponse.identifier
Definition

The Response business identifier. The Response business identifier.

Note This is a business identifer, not a resource identifier (see This is a business identifer, not a resource identifier (see discussion )
Control 0..*
Type Identifier
Summary true
EligibilityResponse.request EligibilityResponse.request[x]
Definition

Original request resource reference. Original request resource reference.

Control 0..1
Type Identifier | Reference ( EligibilityRequest )
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
EligibilityResponse.outcome
Definition

Transaction status: error, complete. Transaction status: error, complete.

Control 0..1
Binding RemittanceOutcome: The outcome of the processing. ( RemittanceOutcome: The outcome of the processing. ( Required )
Type code
Summary true
EligibilityResponse.disposition
Definition

A description of the status of the adjudication. A description of the status of the adjudication.

Control 0..1
Type string
Summary true
EligibilityResponse.ruleset
Definition

The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources. The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources.

Control 0..1
Binding Ruleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. ( Ruleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. ( Example )
Type Coding
Summary true
EligibilityResponse.originalRuleset
Definition

The style (standard) and version of the original material which was converted into this resource. The style (standard) and version of the original material which was converted into this resource.

Control 0..1
Binding Ruleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. ( Ruleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. ( Example )
Type Coding
Requirements

Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated. Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.

Summary true
EligibilityResponse.created
Definition

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

Control 0..1
Type dateTime
Summary true
EligibilityResponse.organization EligibilityResponse.organization[x]
Definition

The Insurer who produced this adjudicated response. The Insurer who produced this adjudicated response.

Control 0..1
Type Identifier | Reference ( Organization )
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
EligibilityResponse.requestProvider EligibilityResponse.requestProvider[x]
Definition

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

Control 0..1
Type Identifier | Reference ( Practitioner )
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
EligibilityResponse.requestOrganization EligibilityResponse.requestOrganization[x]
Definition

The organization which is responsible for the services rendered to the patient. The organization which is responsible for the services rendered to the patient.

Control 0..1
Type Identifier | Reference ( Organization )
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
EligibilityResponse.inforce
Definition

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.

Control | Version History 0..1
Type | Table of Contents boolean | Compare to DSTU1
Summary true
EligibilityResponse.contract
Definition

The contract resource which may provide more detailed information.

Control 0..1
Type Reference ( Contract )
Summary true
EligibilityResponse.form
Definition

The form to be used for printing the content.

Control 0..1
Binding Form Codes: The forms codes. ( Required )
Type Coding
Summary true
EligibilityResponse.benefitBalance
Definition

Benefits and optionally current balances by Category.

Control 0..*
Summary true
EligibilityResponse.benefitBalance.category
Definition

Dental, Vision, Medical, Pharmacy, Rehab etc.

Control 1..1
Binding Benefit Category Codes: Benefit categories such as: oral, medical, vision etc. ( Example )
Type Coding
Summary true
EligibilityResponse.benefitBalance.subCategory
Definition

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

Control 0..1
Binding Benefit SubCategory Codes: Benefit subcategories such as: oral-basic, major, glasses ( Example )
Type Coding
Summary true
EligibilityResponse.benefitBalance.network
Definition

Network designation.

Control 0..1
Binding Network Type Codes: Code to classify in or out of network services ( Example )
Type Coding
Summary true
EligibilityResponse.benefitBalance.unit
Definition

Unit designation: individual or family.

Control 0..1
Binding Unit Type Codes: Unit covered/serviced - individual or family ( Example )
Type Coding
Summary true
EligibilityResponse.benefitBalance.term
Definition

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.

Control 0..1
Binding Benefit Term Codes: Coverage unit - annual, lifetime ( Example )
Type Coding
Summary true
EligibilityResponse.benefitBalance.financial
Definition

Benefits Used to date.

Control 0..*
Summary true
EligibilityResponse.benefitBalance.financial.type
Definition

Deductable, visits, benefit amount.

Control 1..1
Binding Benefit Type Codes: Deductable, visits, co-pay, etc. ( Example )
Type Coding
Summary true
EligibilityResponse.benefitBalance.financial.benefit[x]
Definition

Benefits allowed.

Control 0..1
Type unsignedInt | Money
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
EligibilityResponse.benefitBalance.financial.benefitUsed[x]
Definition

Benefits used.

Control 0..1
Type unsignedInt | Propose a change Money
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
EligibilityResponse.error
Definition

Mutually exclusive with Services Provided (Item).

Control 0..*
Summary true
EligibilityResponse.error.code
Definition

An error code,from a specified code system, which details why the eligibility check could not be performed.

Control 1..1
Binding Adjudication Error Codes: The error codes for adjudication processing. ( Required )
Type Coding
Summary true