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This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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 13.5.5 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.

Summary true Summary Summary Summary Summary Summary
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
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
EligibilityResponse.status
Definition

The status of the resource instance.

Control 1..1
Binding EligibilityResponseStatus: A code specifying the state of the resource instance. ( Required )
Type code
Is Modifier true
Summary true
EligibilityResponse.request EligibilityResponse.request[x]
Definition

Original request resource reference. Original request resource reference.

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

A description of the status of the adjudication.

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

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. ( Example )
Type Coding
EligibilityResponse.disposition EligibilityResponse.originalRuleset
Definition

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

EligibilityResponse.created
Definition

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

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

The Insurer who produced this adjudicated response.

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

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]
EligibilityResponse.ruleset EligibilityResponse.requestOrganization[x]
Definition

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

Control 0..1
Binding Type Ruleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. boolean
EligibilityResponse.contract
Definition

The contract resource which may provide more detailed information.

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

The form to be used for printing the content.

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

Benefits and optionally current balances by Category.

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

The style (standard) and version of the original material which was converted into this resource. Dental, Vision, Medical, Pharmacy, Rehab etc.

Control 0..1 1..1
Binding Ruleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. ( Benefit Category Codes: Benefit categories such as: oral, medical, vision etc. ( Example )
Type Coding
EligibilityResponse.benefitBalance.subCategory
Requirements Definition

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

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

The date when the enclosed suite of services were performed or completed. A short name or tag for the benefit, for example MED01, or DENT2.

Control 0..1
Type dateTime string
EligibilityResponse.benefitBalance.description
Definition

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

Control true 0..1
Type string
EligibilityResponse.organization EligibilityResponse.benefitBalance.network
Definition

The Insurer who produced this adjudicated response. Network designation.

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

Unit designation: individual or family.

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

The practitioner who is responsible for the services rendered to the patient. 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 Reference Coding ( Practitioner
EligibilityResponse.benefitBalance.financial
Definition

Benefits Used to date.

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

Deductable, visits, benefit amount.

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

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

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

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search Benefits used.

Control | Version History 0..1
Type | Table of Contents unsignedInt | Compare to DSTU1 Money
[x] Note See Choice of Data Types for further information about how to use [x]
EligibilityResponse.error
Definition

Mutually exclusive with Services Provided (Item).

Control | 0..*
EligibilityResponse.error.code
Definition

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

Control | Propose a change 1..1
Binding Adjudication Error Codes: The error codes for adjudication processing. ( Required )
Type Coding