DSTU2 STU 3 Ballot
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 (v1.6.0: 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 13.5 Resource EligibilityResponse - Content Resource EligibilityResponse - Content This resource is marked as a draft .

This resource provides eligibility and plan details from the processing of an Eligibility resource.
Financial Management Financial Management Work Group Work Group Maturity Level : 0 Maturity Level : 1 Compartments : Not linked to any defined compartments : Not linked to any defined compartments

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

7.5.1 Scope and Usage 13.5.1 Scope and Usage This resource has not yet undergone proper review by FM. At this time, it is to be considered as a draft. The EligibilityResponse resource provides eligibility and plan details from the processing of an Eligibility resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy details. Todo

The EligibilityResponse resource provides eligibility and plan details from the processing of an EligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy details.

7.5.2 Resource Content 13.5.2 Resource Content

Structure

Σ DomainResource Σ Claim reference Σ Σ Σ Coding Σ dateTime Σ Σ
Name Flags Card. Type Description & Constraints Description & Constraints doco
. . EligibilityResponse DomainResource EligibilityResponse resource
. . . identifier 0..* Identifier EligibilityResponse resource Business Identifier
. . identifier . status ?! Σ 0..* 1..1 Identifier code Business Identifier active | cancelled | draft | entered-in-error
EligibilityResponseStatus ( Required )
. . request . request[x] 0..1 Claim reference
.... requestIdentifier 0..1 Identifier
. . . . requestReference Reference ( EligibilityRequest )
. . . outcome 0..1 code complete | error complete | error | partial
RemittanceOutcome ( ( Required )
. . . disposition 0..1 string Disposition Message Disposition Message
. . . ruleset 0..1 Coding Resource version
Σ Ruleset Codes ( Example )
... originalRuleset 0..1 Coding Resource version Original version
Ruleset Codes ( Ruleset Codes ( Example )
. . originalRuleset . created 0..1 dateTime Creation date
. . . organization[x] 0..1 Insurer
. . . . organizationIdentifier Identifier
. . . . organizationReference Original version Ruleset Codes Reference ( Example Organization )
. created . . requestProvider[x] 0..1 Responsible practitioner
.... requestProviderIdentifier Identifier
.... requestProviderReference Reference ( Practitioner )
... requestOrganization[x] 0..1 Responsible organization
. . . . requestOrganizationIdentifier Identifier
. . . . requestOrganizationReference Creation date Reference ( Organization )
. . organization . inforce 0..1 boolean Coverage inforce
. . . contract 0..1 Reference ( Organization Contract ) Insurer Contract details
. . requestProvider . form 0..1 Coding Printed Form Identifier
Σ Form Codes ( Required )
... benefitBalance 0..* BackboneElement Benefits by Category
.... category 1..1 Coding Benefit Category
Benefit Category Codes ( Example )
.... subCategory 0..1 Reference Coding ( Practitioner Benefit SubCategory
Benefit SubCategory Codes ( Example )
. . . . name 0..1 Responsible practitioner string Short name for the benefit
. requestOrganization . . . description 0..1 string Description of the benefit
. . . . network 0..1 Reference Coding ( Organization In or out of network
Network Type Codes ( Example )
. . . . unit Responsible organization 0..1 Coding Individual or family
Unit Type Codes ( Example )
.... term 0..1 Coding Annual or lifetime
Benefit Term Codes ( Example )
.... financial 0..* BackboneElement Benefit Summary
..... type 1..1 Coding Deductable, visits, benefit amount
Benefit Type Codes ( Example )
..... benefit[x] 0..1 Benefits allowed
...... benefitUnsignedInt unsignedInt
...... benefitString string
...... benefitMoney Money
..... benefitUsed[x] 0..1 Benefits used
...... benefitUsedUnsignedInt unsignedInt
...... benefitUsedMoney Money
... error 0..* BackboneElement Processing errors
.... code 1..1 Coding Error code detailing processing issues
Adjudication Error Codes ( Required )

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram ( Legend )

EligibilityResponse ( ( DomainResource ) The Response business identifier The Response business identifier identifier : : Identifier [0..*] [0..*] Original request resource reference The status of the resource instance (this element modifies the meaning of other elements) request status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required) EligibilityResponseStatus ! » Original request resource reference request[x] : Type [0..1] « Identifier : | Reference [0..1] « ( EligibilityRequest » ) » Transaction status: error, complete Transaction status: error, complete outcome : : code [0..1] « [0..1] « The outcome of the processing. (Strength=Required) The outcome of the processing. (Strength=Required) RemittanceOutcome ! » ! » A description of the status of the adjudication A description of the status of the adjudication disposition : : string [0..1] [0..1] 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 ruleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » Ruleset ?? » 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 originalRuleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » Ruleset ?? » The date when the enclosed suite of services were performed or completed The date when the enclosed suite of services were performed or completed created : : dateTime [0..1] [0..1] The Insurer who produced this adjudicated response The Insurer who produced this adjudicated response organization organization[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Organization » ) » The practitioner who is responsible for the services rendered to the patient The practitioner who is responsible for the services rendered to the patient requestProvider requestProvider[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner » ) » The organization which is responsible for the services rendered to the patient The organization which is responsible for the services rendered to the patient requestOrganization requestOrganization[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Organization » ) » Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates inforce : boolean [0..1] The contract resource which may provide more detailed information contract : Reference [0..1] « Contract » The form to be used for printing the content form : Coding [0..1] « The forms codes. (Strength=Required) Form ! » Benefits Dental, Vision, Medical, Pharmacy, Rehab etc category : Coding [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? » Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? » A short name or tag for the benefit, for example MED01, or DENT2 name : string [0..1] A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services' description : string [0..1] Network designation network : Coding [0..1] « Code to classify in or out of network services (Strength=Example) Network Type ?? » Unit designation: individual or family unit : Coding [0..1] « Unit covered/serviced - individual or family (Strength=Example) Unit Type ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis' term : Coding [0..1] « Coverage unit - annual, lifetime (Strength=Example) Benefit Term ?? » Benefit Deductable, visits, benefit amount type : Coding [1..1] « Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? » Benefits allowed benefit[x] : Type [0..1] « unsignedInt | string | Money » Benefits used benefitUsed[x] : Type [0..1] « unsignedInt | Money » Errors An error code,from a specified code system, which details why the eligibility check could not be performed code : Coding [1..1] « The error codes for adjudication processing. (Strength=Required) Adjudication Error ! » Benefits Used to date financial [0..*] Benefits and optionally current balances by Category benefitBalance [0..*] Mutually exclusive with Services Provided (Item) error [0..*]

XML Template XML Template < 

<EligibilityResponse xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <
 <
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>

 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <request[x]><!-- 0..1 Identifier|Reference(EligibilityRequest) Claim reference --></request[x]>
 <outcome value="[code]"/><!-- 0..1 complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></organization[x]>
 <requestProvider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></requestProvider[x]>
 <requestOrganization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></requestOrganization[x]>
 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce -->
 <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <benefitBalance>  <!-- 0..* Benefits by Category -->
  <category><!-- 1..1 Coding Benefit Category --></category>
  <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory>
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit -->
  <network><!-- 0..1 Coding In or out of network --></network>
  <unit><!-- 0..1 Coding Individual or family --></unit>
  <term><!-- 0..1 Coding Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 Coding Deductable, visits, benefit amount --></type>
   <benefit[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Money Benefits used --></benefitUsed[x]>
  </financial>
 </benefitBalance>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>

</EligibilityResponse>

JSON Template JSON Template { "resourceType" : "", 

{doco
  "resourceType" : "EligibilityResponse",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  // request[x]: Claim reference. One of these 2:

  "requestIdentifier" : { Identifier },
  "requestReference" : { Reference(EligibilityRequest) },
  "outcome" : "<code>", // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  // organization[x]: Insurer. One of these 2:

  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  // requestProvider[x]: Responsible practitioner. One of these 2:

  "requestProviderIdentifier" : { Identifier },
  "requestProviderReference" : { Reference(Practitioner) },
  // requestOrganization[x]: Responsible organization. One of these 2:

  "requestOrganizationIdentifier" : { Identifier },
  "requestOrganizationReference" : { Reference(Organization) },
  "inforce" : <boolean>, // Coverage inforce
  "contract" : { Reference(Contract) }, // Contract details
  "form" : { Coding }, // Printed Form Identifier
  "benefitBalance" : [{ // Benefits by Category
    "category" : { Coding }, // R!  Benefit Category
    "subCategory" : { Coding }, // Benefit SubCategory
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit
    "network" : { Coding }, // In or out of network
    "unit" : { Coding }, // Individual or family
    "term" : { Coding }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { Coding }, // R!  Deductable, visits, benefit amount
      // benefit[x]: Benefits allowed. One of these 3:

      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitString" : "<string>",
      "benefitMoney" : { Money },
      // benefitUsed[x]: Benefits used. One of these 2:

      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedMoney" : { Money }
    }]
  }],
  "error" : [{ // Processing errors
    "code" : { Coding } // R!  Error code detailing processing issues
  }]

}

Turtle Template 


@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:EligibilityResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  # EligibilityResponse.request[x] : 0..1 Claim reference. One of these 2
    fhir:EligibilityResponse.requestIdentifier [ Identifier ]
    fhir:EligibilityResponse.requestReference [ Reference(EligibilityRequest) ]
  fhir:EligibilityResponse.outcome [ code ]; # 0..1 complete | error | partial
  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.ruleset [ Coding ]; # 0..1 Resource version
  fhir:EligibilityResponse.originalRuleset [ Coding ]; # 0..1 Original version
  fhir:EligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  # EligibilityResponse.organization[x] : 0..1 Insurer. One of these 2
    fhir:EligibilityResponse.organizationIdentifier [ Identifier ]
    fhir:EligibilityResponse.organizationReference [ Reference(Organization) ]
  # EligibilityResponse.requestProvider[x] : 0..1 Responsible practitioner. One of these 2
    fhir:EligibilityResponse.requestProviderIdentifier [ Identifier ]
    fhir:EligibilityResponse.requestProviderReference [ Reference(Practitioner) ]
  # EligibilityResponse.requestOrganization[x] : 0..1 Responsible organization. One of these 2
    fhir:EligibilityResponse.requestOrganizationIdentifier [ Identifier ]
    fhir:EligibilityResponse.requestOrganizationReference [ Reference(Organization) ]
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce
  fhir:EligibilityResponse.contract [ Reference(Contract) ]; # 0..1 Contract details
  fhir:EligibilityResponse.form [ Coding ]; # 0..1 Printed Form Identifier
  fhir:EligibilityResponse.benefitBalance [ # 0..* Benefits by Category
    fhir:EligibilityResponse.benefitBalance.category [ Coding ]; # 1..1 Benefit Category
    fhir:EligibilityResponse.benefitBalance.subCategory [ Coding ]; # 0..1 Benefit SubCategory
    fhir:EligibilityResponse.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:EligibilityResponse.benefitBalance.description [ string ]; # 0..1 Description of the benefit
    fhir:EligibilityResponse.benefitBalance.network [ Coding ]; # 0..1 In or out of network
    fhir:EligibilityResponse.benefitBalance.unit [ Coding ]; # 0..1 Individual or family
    fhir:EligibilityResponse.benefitBalance.term [ Coding ]; # 0..1 Annual or lifetime
    fhir:EligibilityResponse.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:EligibilityResponse.benefitBalance.financial.type [ Coding ]; # 1..1 Deductable, visits, benefit amount
      # EligibilityResponse.benefitBalance.financial.benefit[x] : 0..1 Benefits allowed. One of these 3
        fhir:EligibilityResponse.benefitBalance.financial.benefitUnsignedInt [ unsignedInt ]
        fhir:EligibilityResponse.benefitBalance.financial.benefitString [ string ]
        fhir:EligibilityResponse.benefitBalance.financial.benefitMoney [ Money ]
      # EligibilityResponse.benefitBalance.financial.benefitUsed[x] : 0..1 Benefits used. One of these 2
        fhir:EligibilityResponse.benefitBalance.financial.benefitUsedUnsignedInt [ unsignedInt ]
        fhir:EligibilityResponse.benefitBalance.financial.benefitUsedMoney [ Money ]
    ], ...;
  ], ...;
  fhir:EligibilityResponse.error [ # 0..* Processing errors
    fhir:EligibilityResponse.error.code [ Coding ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since DSTU2

EligibilityResponse
EligibilityResponse.status added
EligibilityResponse.request[x] Renamed from request to request[x]
Add Identifier
EligibilityResponse.organization[x] Renamed from organization to organization[x]
Add Identifier
EligibilityResponse.requestProvider[x] Renamed from requestProvider to requestProvider[x]
Add Identifier
EligibilityResponse.requestOrganization[x] Renamed from requestOrganization to requestOrganization[x]
Add Identifier
EligibilityResponse.inforce added
EligibilityResponse.contract added
EligibilityResponse.form added
EligibilityResponse.benefitBalance added
EligibilityResponse.benefitBalance.category added
EligibilityResponse.benefitBalance.subCategory added
EligibilityResponse.benefitBalance.name added
EligibilityResponse.benefitBalance.description added
EligibilityResponse.benefitBalance.network added
EligibilityResponse.benefitBalance.unit added
EligibilityResponse.benefitBalance.term added
EligibilityResponse.benefitBalance.financial added
EligibilityResponse.benefitBalance.financial.type added
EligibilityResponse.benefitBalance.financial.benefit[x] added
EligibilityResponse.benefitBalance.financial.benefitUsed[x] added
EligibilityResponse.error added
EligibilityResponse.error.code added

See the Full Difference for further information

Structure

Σ DomainResource Σ Claim reference Σ Σ Σ Coding Σ dateTime Σ requestOrganization Σ
Name Flags Card. Type Description & Constraints Description & Constraints doco
. . EligibilityResponse DomainResource EligibilityResponse resource
. . . identifier 0..* Identifier EligibilityResponse resource Business Identifier
. . identifier . status ?! Σ 0..* 1..1 Identifier code Business Identifier active | cancelled | draft | entered-in-error
EligibilityResponseStatus ( Required )
. . request . request[x] 0..1 Claim reference
.... requestIdentifier 0..1 Identifier
. . . . requestReference Reference ( EligibilityRequest )
. . . outcome 0..1 code complete | error complete | error | partial
RemittanceOutcome ( ( Required )
. . . disposition 0..1 string Disposition Message Disposition Message
. . . ruleset 0..1 Coding Resource version
Σ Ruleset Codes ( Example )
... originalRuleset 0..1 Coding Resource version Original version
Ruleset Codes ( Ruleset Codes ( Example )
. . originalRuleset . created 0..1 dateTime Creation date
. . . organization[x] 0..1 Insurer
. . . . organizationIdentifier Identifier
. . . . organizationReference Original version Ruleset Codes Reference ( Example Organization )
. created . . requestProvider[x] 0..1 Responsible practitioner
.... requestProviderIdentifier Identifier
.... requestProviderReference Reference ( Practitioner )
... requestOrganization[x] 0..1 Responsible organization
. . . . requestOrganizationIdentifier Identifier
. . . . requestOrganizationReference Creation date Reference ( Organization )
. . organization . inforce 0..1 boolean Coverage inforce
. . . contract 0..1 Reference ( Organization Contract ) Insurer Contract details
. . requestProvider . form 0..1 Coding Printed Form Identifier
Σ Form Codes ( Required )
... benefitBalance 0..* BackboneElement Benefits by Category
.... category 1..1 Coding Benefit Category
Benefit Category Codes ( Example )
.... subCategory 0..1 Reference Coding ( Practitioner Benefit SubCategory
Benefit SubCategory Codes ( Example )
. . . . name Responsible practitioner 0..1 string Short name for the benefit
. . . . description 0..1 string Description of the benefit
. . . . network 0..1 Reference Coding ( Organization In or out of network
Network Type Codes ( Example )
. . . . unit Responsible organization 0..1 Coding Individual or family
Unit Type Codes ( Example )
.... term 0..1 Coding Annual or lifetime
Benefit Term Codes ( Example )
.... financial 0..* BackboneElement Benefit Summary
..... type 1..1 Coding Deductable, visits, benefit amount
Benefit Type Codes ( Example )
..... benefit[x] 0..1 Benefits allowed
...... benefitUnsignedInt unsignedInt
...... benefitString string
...... benefitMoney Money
..... benefitUsed[x] 0..1 Benefits used
...... benefitUsedUnsignedInt unsignedInt
...... benefitUsedMoney Money
... error 0..* BackboneElement Processing errors
.... code 1..1 Coding Error code detailing processing issues
Adjudication Error Codes ( Required )

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram ( Legend )

EligibilityResponse ( ( DomainResource ) The Response business identifier The Response business identifier identifier : : Identifier [0..*] [0..*] Original request resource reference The status of the resource instance (this element modifies the meaning of other elements) request status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required) EligibilityResponseStatus ! » Original request resource reference request[x] : Type [0..1] « Identifier : | Reference [0..1] « ( EligibilityRequest » ) » Transaction status: error, complete Transaction status: error, complete outcome : : code [0..1] « [0..1] « The outcome of the processing. (Strength=Required) The outcome of the processing. (Strength=Required) RemittanceOutcome ! » ! » A description of the status of the adjudication A description of the status of the adjudication disposition : : string [0..1] [0..1] 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 ruleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » Ruleset ?? » 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 originalRuleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » Ruleset ?? » The date when the enclosed suite of services were performed or completed The date when the enclosed suite of services were performed or completed created : : dateTime [0..1] [0..1] The Insurer who produced this adjudicated response The Insurer who produced this adjudicated response organization organization[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Organization » ) » The practitioner who is responsible for the services rendered to the patient The practitioner who is responsible for the services rendered to the patient requestProvider requestProvider[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner » ) » The organization which is responsible for the services rendered to the patient The organization which is responsible for the services rendered to the patient requestOrganization requestOrganization[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Organization » ) » Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates inforce : boolean [0..1] The contract resource which may provide more detailed information contract : Reference [0..1] « Contract » The form to be used for printing the content form : Coding [0..1] « The forms codes. (Strength=Required) Form ! » Benefits Dental, Vision, Medical, Pharmacy, Rehab etc category : Coding [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? » Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : Coding [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? » A short name or tag for the benefit, for example MED01, or DENT2 name : string [0..1] A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services' description : string [0..1] Network designation network : Coding [0..1] « Code to classify in or out of network services (Strength=Example) Network Type ?? » Unit designation: individual or family unit : Coding [0..1] « Unit covered/serviced - individual or family (Strength=Example) Unit Type ?? » The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis' term : Coding [0..1] « Coverage unit - annual, lifetime (Strength=Example) Benefit Term ?? » Benefit Deductable, visits, benefit amount type : Coding [1..1] « Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? » Benefits allowed benefit[x] : Type [0..1] « unsignedInt | string | Money » Benefits used benefitUsed[x] : Type [0..1] « unsignedInt | Money » Errors An error code,from a specified code system, which details why the eligibility check could not be performed code : Coding [1..1] « The error codes for adjudication processing. (Strength=Required) Adjudication Error ! » Benefits Used to date financial [0..*] Benefits and optionally current balances by Category benefitBalance [0..*] Mutually exclusive with Services Provided (Item) error [0..*]

XML Template XML Template < 

<EligibilityResponse xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <
 <
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>

 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <request[x]><!-- 0..1 Identifier|Reference(EligibilityRequest) Claim reference --></request[x]>
 <outcome value="[code]"/><!-- 0..1 complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></organization[x]>
 <requestProvider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></requestProvider[x]>
 <requestOrganization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></requestOrganization[x]>
 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce -->
 <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <benefitBalance>  <!-- 0..* Benefits by Category -->
  <category><!-- 1..1 Coding Benefit Category --></category>
  <subCategory><!-- 0..1 Coding Benefit SubCategory --></subCategory>
  <name value="[string]"/><!-- 0..1 Short name for the benefit -->
  <description value="[string]"/><!-- 0..1 Description of the benefit -->
  <network><!-- 0..1 Coding In or out of network --></network>
  <unit><!-- 0..1 Coding Individual or family --></unit>
  <term><!-- 0..1 Coding Annual or lifetime --></term>
  <financial>  <!-- 0..* Benefit Summary -->
   <type><!-- 1..1 Coding Deductable, visits, benefit amount --></type>
   <benefit[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></benefit[x]>
   <benefitUsed[x]><!-- 0..1 unsignedInt|Money Benefits used --></benefitUsed[x]>
  </financial>
 </benefitBalance>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>

</EligibilityResponse>

JSON Template JSON Template { "resourceType" : "", 

{doco
  "resourceType" : "EligibilityResponse",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  // request[x]: Claim reference. One of these 2:

  "requestIdentifier" : { Identifier },
  "requestReference" : { Reference(EligibilityRequest) },
  "outcome" : "<code>", // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  // organization[x]: Insurer. One of these 2:

  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  // requestProvider[x]: Responsible practitioner. One of these 2:

  "requestProviderIdentifier" : { Identifier },
  "requestProviderReference" : { Reference(Practitioner) },
  // requestOrganization[x]: Responsible organization. One of these 2:

  "requestOrganizationIdentifier" : { Identifier },
  "requestOrganizationReference" : { Reference(Organization) },
  "inforce" : <boolean>, // Coverage inforce
  "contract" : { Reference(Contract) }, // Contract details
  "form" : { Coding }, // Printed Form Identifier
  "benefitBalance" : [{ // Benefits by Category
    "category" : { Coding }, // R!  Benefit Category
    "subCategory" : { Coding }, // Benefit SubCategory
    "name" : "<string>", // Short name for the benefit
    "description" : "<string>", // Description of the benefit
    "network" : { Coding }, // In or out of network
    "unit" : { Coding }, // Individual or family
    "term" : { Coding }, // Annual or lifetime
    "financial" : [{ // Benefit Summary
      "type" : { Coding }, // R!  Deductable, visits, benefit amount
      // benefit[x]: Benefits allowed. One of these 3:

      "benefitUnsignedInt" : "<unsignedInt>",
      "benefitString" : "<string>",
      "benefitMoney" : { Money },
      // benefitUsed[x]: Benefits used. One of these 2:

      "benefitUsedUnsignedInt" : "<unsignedInt>"
      "benefitUsedMoney" : { Money }
    }]
  }],
  "error" : [{ // Processing errors
    "code" : { Coding } // R!  Error code detailing processing issues
  }]

}
 
Alternate
definitions:

Turtle Template 


@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:EligibilityResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:EligibilityResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  # EligibilityResponse.request[x] : 0..1 Claim reference. One of these 2
    fhir:EligibilityResponse.requestIdentifier [ Identifier ]
    fhir:EligibilityResponse.requestReference [ Reference(EligibilityRequest) ]
  fhir:EligibilityResponse.outcome [ code ]; # 0..1 complete | error | partial
  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.ruleset [ Coding ]; # 0..1 Resource version
  fhir:EligibilityResponse.originalRuleset [ Coding ]; # 0..1 Original version
  fhir:EligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  # EligibilityResponse.organization[x] : 0..1 Insurer. One of these 2
    fhir:EligibilityResponse.organizationIdentifier [ Identifier ]
    fhir:EligibilityResponse.organizationReference [ Reference(Organization) ]
  # EligibilityResponse.requestProvider[x] : 0..1 Responsible practitioner. One of these 2
    fhir:EligibilityResponse.requestProviderIdentifier [ Identifier ]
    fhir:EligibilityResponse.requestProviderReference [ Reference(Practitioner) ]
  # EligibilityResponse.requestOrganization[x] : 0..1 Responsible organization. One of these 2
    fhir:EligibilityResponse.requestOrganizationIdentifier [ Identifier ]
    fhir:EligibilityResponse.requestOrganizationReference [ Reference(Organization) ]
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce
  fhir:EligibilityResponse.contract [ Reference(Contract) ]; # 0..1 Contract details
  fhir:EligibilityResponse.form [ Coding ]; # 0..1 Printed Form Identifier
  fhir:EligibilityResponse.benefitBalance [ # 0..* Benefits by Category
    fhir:EligibilityResponse.benefitBalance.category [ Coding ]; # 1..1 Benefit Category
    fhir:EligibilityResponse.benefitBalance.subCategory [ Coding ]; # 0..1 Benefit SubCategory
    fhir:EligibilityResponse.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
    fhir:EligibilityResponse.benefitBalance.description [ string ]; # 0..1 Description of the benefit
    fhir:EligibilityResponse.benefitBalance.network [ Coding ]; # 0..1 In or out of network
    fhir:EligibilityResponse.benefitBalance.unit [ Coding ]; # 0..1 Individual or family
    fhir:EligibilityResponse.benefitBalance.term [ Coding ]; # 0..1 Annual or lifetime
    fhir:EligibilityResponse.benefitBalance.financial [ # 0..* Benefit Summary
      fhir:EligibilityResponse.benefitBalance.financial.type [ Coding ]; # 1..1 Deductable, visits, benefit amount
      # EligibilityResponse.benefitBalance.financial.benefit[x] : 0..1 Benefits allowed. One of these 3
        fhir:EligibilityResponse.benefitBalance.financial.benefitUnsignedInt [ unsignedInt ]
        fhir:EligibilityResponse.benefitBalance.financial.benefitString [ string ]
        fhir:EligibilityResponse.benefitBalance.financial.benefitMoney [ Money ]
      # EligibilityResponse.benefitBalance.financial.benefitUsed[x] : 0..1 Benefits used. One of these 2
        fhir:EligibilityResponse.benefitBalance.financial.benefitUsedUnsignedInt [ unsignedInt ]
        fhir:EligibilityResponse.benefitBalance.financial.benefitUsedMoney [ Money ]
    ], ...;
  ], ...;
  fhir:EligibilityResponse.error [ # 0..* Processing errors
    fhir:EligibilityResponse.error.code [ Coding ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since DSTU2

EligibilityResponse
EligibilityResponse.status added
EligibilityResponse.request[x] Renamed from request to request[x]
Add Identifier
EligibilityResponse.organization[x] Renamed from organization to organization[x]
Add Identifier
EligibilityResponse.requestProvider[x] Renamed from requestProvider to requestProvider[x]
Add Identifier
EligibilityResponse.requestOrganization[x] Renamed from requestOrganization to requestOrganization[x]
Add Identifier
EligibilityResponse.inforce added
EligibilityResponse.contract added
EligibilityResponse.form added
EligibilityResponse.benefitBalance added
EligibilityResponse.benefitBalance.category added
EligibilityResponse.benefitBalance.subCategory added
EligibilityResponse.benefitBalance.name added
EligibilityResponse.benefitBalance.description added
EligibilityResponse.benefitBalance.network added
EligibilityResponse.benefitBalance.unit added
EligibilityResponse.benefitBalance.term added
EligibilityResponse.benefitBalance.financial added
EligibilityResponse.benefitBalance.financial.type added
EligibilityResponse.benefitBalance.financial.benefit[x] added
EligibilityResponse.benefitBalance.financial.benefitUsed[x] added
EligibilityResponse.error added
EligibilityResponse.error.code added

See the Full Difference for further information

 

Alternate definitions: Master Definition ( XML , JSON ), XML Schema / Schematron , Resource Profile ( XML , (for ) + JSON Schema , ShEx (for Turtle ), Questionnaire )

7.5.2.1 Terminology Bindings 13.5.2.1 Terminology Bindings

Path Definition Type Reference
EligibilityResponse.status A code specifying the state of the resource instance. Required EligibilityResponse.outcome The outcome of the processing. EligibilityResponseStatus
EligibilityResponse.outcome The outcome of the processing. Required RemittanceOutcome
EligibilityResponse.ruleset
EligibilityResponse.originalRuleset EligibilityResponse.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version. The static and dynamic model to which contents conform, which may be business version or standard/version. Example Ruleset Codes Ruleset Codes
EligibilityResponse.form The forms codes. Required Form Codes
EligibilityResponse.benefitBalance.category Benefit categories such as: oral, medical, vision etc. Example Benefit Category Codes
EligibilityResponse.benefitBalance.subCategory Benefit subcategories such as: oral-basic, major, glasses Example Benefit SubCategory Codes
EligibilityResponse.benefitBalance.network Code to classify in or out of network services Example Network Type Codes
EligibilityResponse.benefitBalance.unit Unit covered/serviced - individual or family Example Unit Type Codes
EligibilityResponse.benefitBalance.term Coverage unit - annual, lifetime Example Benefit Term Codes
EligibilityResponse.benefitBalance.financial.type Deductable, visits, co-pay, etc. Example Benefit Type Codes
EligibilityResponse.error.code The error codes for adjudication processing. Required Adjudication Error Codes

7.5.3 Search Parameters 13.5.3 Search Parameters Search parameters for this resource. The common parameters also apply. See

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services. for more information about searching in REST, messaging, and services.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100.
Name Type Description Paths
created date The creation date EligibilityResponse.created
disposition string The contents of the disposition message EligibilityResponse.disposition
identifier token The business identifier of the Explanation of Benefit The business identifier EligibilityResponse.identifier
organization-identifier token The organization which generated this resource EligibilityResponse.organizationIdentifier
organization-reference reference The organization which generated this resource EligibilityResponse.organizationReference
Links: Search ( Organization )
outcome token | Version History The processing outcome EligibilityResponse.outcome
request-identifier token | Table of Contents The EligibilityRequest reference EligibilityResponse.requestIdentifier
request-organization-identifier token | Compare to DSTU1 The EligibilityRequest organization EligibilityResponse.requestOrganizationIdentifier
request-organization-reference reference | The EligibilityRequest organization EligibilityResponse.requestOrganizationReference
( Organization | Propose a change )
request-provider-identifier token The EligibilityRequest provider EligibilityResponse.requestProviderIdentifier
request-provider-reference reference The EligibilityRequest provider EligibilityResponse.requestProviderReference
( Practitioner try { var currentTabIndex = sessionStorage.getItem('fhir-resource-tab-index'); } catch(exception){ } if (!currentTabIndex) currentTabIndex = '0'; $( '#tabs' ).tabs({ active: currentTabIndex, activate: function( event, ui ) { var active = $('.selector').tabs('option', 'active'); currentTabIndex = ui.newTab.index(); document.activeElement.blur(); try { sessionStorage.setItem('fhir-resource-tab-index', currentTabIndex); } catch(exception){ } } });
request-reference reference The EligibilityRequest reference EligibilityResponse.requestReference
( EligibilityRequest )