FHIR Release 3 (STU) R4 Ballot #1 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.0.2: STU 3). (v3.3.0: R4 Ballot 2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R3 R2

13.2 Resource EligibilityRequest - Content

Financial Management Work Group Maturity Level : 2   Trial Use Compartments : Patient , Practitioner

The EligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an EligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.

13.2.1 Scope and Usage

The EligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an Eligibility Response, with information regarding whether the stated coverage is valid and in-force, and potentially the amount of coverage which may be available to any services classes identified in this request. Todo

For Balloters: The optional Authorization subclass has been added for comment ballot review. It is intended to convey the billable services which may be performed and for which the provider wishes to determine whether it needs to submit a prior authorization (pre-authorization) request. The EligibilityResponse would return a boolean flag indicating whether prior authorization is required and an optional text element would convey any special instructions.

This resource is referenced by eligibilityresponse

13.2.2 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
. . EligibilityRequest TU DomainResource Determine insurance validity and scope of coverage
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier
. . . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . priority 0..1 CodeableConcept Desired processing priority
Process Priority Codes ( Example )
. . . patient 0..1 Reference ( Patient ) The subject of the Products and Services
. . . serviced[x] 0..1 Estimated date or dates of Service
. . . . servicedDate date
. . . . servicedPeriod Period
. . . created 0..1 dateTime Creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author
. . . provider 0..1 Reference ( Practitioner ) Responsible practitioner organization 0..1 Reference | PractitionerRole ( | Organization ) Responsible organization practitioner
. . . insurer 0..1 Reference ( Organization ) Target
. . . facility 0..1 Reference ( Location ) Servicing Facility
. . . coverage 0..1 Reference ( Coverage ) Insurance or medical plan
. . . businessArrangement 0..1 string Business agreement
. . . benefitCategory 0..1 CodeableConcept Type of services covered
Benefit Category Codes ( Example )
. . . benefitSubCategory 0..1 CodeableConcept Detailed services covered within the type
Benefit SubCategory Codes ( Example )
. . . authorization 0..* BackboneElement Services which may require prior authorization
.... sequence 1..1 positiveInt Procedure sequence for reference
.... service 1..1 CodeableConcept Billing Code
USCLS Codes ( Example )
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per point
.... facility 0..1 Reference ( Location | Organization ) Servicing Facility
.... diagnosis 0..* BackboneElement List of Diagnosis
..... diagnosis[x] 0..1 Patient's diagnosis
ICD-10 Codes ( Example )
...... diagnosisCodeableConcept CodeableConcept
...... diagnosisReference Reference ( Condition )

doco Documentation for this format

UML Diagram ( Legend )

EligibilityRequest ( DomainResource ) The Response business identifier identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status ! » Immediate (STAT), best effort (NORMAL), deferred (DEFER) priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example) Process Priority ?? » Patient Resource patient : Reference [0..1] « Patient » The date or dates when the enclosed suite of services were performed or completed serviced[x] : Type [0..1] « date | Period » The date when this resource was created created : dateTime [0..1] Person who created the invoice/claim/pre-determination or pre-authorization enterer : Reference [0..1] « Practitioner | PractitionerRole » The practitioner who is responsible for the services rendered to the patient provider : Reference [0..1] « Practitioner | PractitionerRole | The organization which is responsible for the services rendered to the patient organization : Reference [0..1] Organization » The Insurer who is target of the request insurer : Reference [0..1] « Organization » Facility where the services were provided facility : Reference [0..1] « Location » Financial instrument by which payment information for health care coverage : Reference [0..1] « Coverage » The contract number of a business agreement which describes the terms and conditions businessArrangement : string [0..1] Dental, Vision, Medical, Pharmacy, Rehab etc benefitCategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? » Dental: basic, major, ortho; Vision exam, glasses, contacts; etc benefitSubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? » Authorization Sequence of procedures which serves to order and provide a link sequence : positiveInt [1..1] A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) service : CodeableConcept [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » Item typification or modifiers codes, eg for 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 modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The fee for an addittional service or product or charge unitPrice : Money [0..1] Facility where the services were provided facility : Reference [0..1] « Location | Organization » Diagnosis The diagnosis diagnosis[x] : Type [0..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? » List of patient diagnosis for which care is sought diagnosis [0..*] A list of billable services for which an authorization prior to service delivery may be required by the payor authorization [0..*]

XML Template 

<

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

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <

 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->

 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <
 <</enterer>
 <</provider>
 <</organization>

 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></provider>

 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <

 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->

 <benefitCategory><!-- 0..1 CodeableConcept Type of services covered --></benefitCategory>
 <benefitSubCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></benefitSubCategory>
 <authorization>  <!-- 0..* Services which may require prior authorization -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <service><!-- 1..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>
  <diagnosis>  <!-- 0..* List of Diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  </diagnosis>
 </authorization>

</EligibilityRequest>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "EligibilityRequest",

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

  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "priority" : { CodeableConcept }, // Desired processing priority
  "patient" : { Reference(Patient) }, // The subject of the Products and Services

  // serviced[x]: Estimated date or dates of Service. One of these 2:
  ">",
  " },
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "insurer" : { Reference(Organization) }, // Target
  "facility" : { Reference(Location) }, // Servicing Facility
  "coverage" : { Reference(Coverage) }, // Insurance or medical plan
  "businessArrangement" : "<string>", // Business agreement
  "benefitCategory" : { CodeableConcept }, // Type of services covered
  "benefitSubCategory" : { CodeableConcept }, // Detailed services covered within the type
  "authorization" : [{ // Services which may require prior authorization
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "service" : { CodeableConcept }, // R!  Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "facility" : { Reference(Location|Organization) }, // Servicing Facility
    "diagnosis" : [{ // List of Diagnosis
      // diagnosis[x]: Patient's diagnosis. One of these 2:

      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }]
  }]

}

Turtle Template 

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


[ a fhir:EligibilityRequest;
  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:EligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityRequest.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:EligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # EligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2
    fhir:EligibilityRequest.servicedDate [ date ]
    fhir:EligibilityRequest.servicedPeriod [ Period ]
  fhir:EligibilityRequest.created [ dateTime ]; # 0..1 Creation date
  fhir:
  fhir:
  fhir:

  fhir:EligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:EligibilityRequest.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner

  fhir:EligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:EligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:EligibilityRequest.coverage [ Reference(Coverage) ]; # 0..1 Insurance or medical plan
  fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement
  fhir:EligibilityRequest.benefitCategory [ CodeableConcept ]; # 0..1 Type of services covered
  fhir:EligibilityRequest.benefitSubCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
  fhir:EligibilityRequest.authorization [ # 0..* Services which may require prior authorization
    fhir:EligibilityRequest.authorization.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:EligibilityRequest.authorization.service [ CodeableConcept ]; # 1..1 Billing Code
    fhir:EligibilityRequest.authorization.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:EligibilityRequest.authorization.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:EligibilityRequest.authorization.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:EligibilityRequest.authorization.facility [ Reference(Location|Organization) ]; # 0..1 Servicing Facility
    fhir:EligibilityRequest.authorization.diagnosis [ # 0..* List of Diagnosis
      # EligibilityRequest.authorization.diagnosis.diagnosis[x] : 0..1 Patient's diagnosis. One of these 2
        fhir:EligibilityRequest.authorization.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:EligibilityRequest.authorization.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
  ], ...;

]

Changes since DSTU2 R3

EligibilityRequest
EligibilityRequest.status EligibilityRequest.enterer
  • Added Element Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole)
EligibilityRequest.priority EligibilityRequest.provider
  • Added Element Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization)
EligibilityRequest.patient EligibilityRequest.authorization
  • Added Element
EligibilityRequest.serviced[x] EligibilityRequest.authorization.sequence
  • Added Element
EligibilityRequest.enterer EligibilityRequest.authorization.service
  • Added Element
EligibilityRequest.insurer EligibilityRequest.authorization.modifier
  • Added Element
EligibilityRequest.facility EligibilityRequest.authorization.quantity
  • Added Element
EligibilityRequest.coverage EligibilityRequest.authorization.unitPrice
  • Added Element
EligibilityRequest.businessArrangement EligibilityRequest.authorization.facility
  • Added Element
EligibilityRequest.benefitCategory EligibilityRequest.authorization.diagnosis
  • Added Element
EligibilityRequest.benefitSubCategory EligibilityRequest.authorization.diagnosis.diagnosis[x]
  • Added Element
EligibilityRequest.ruleset deleted EligibilityRequest.originalRuleset deleted EligibilityRequest.target EligibilityRequest.organization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

Structure

Name Flags Card. Type Description & Constraints doco
. . EligibilityRequest TU DomainResource Determine insurance validity and scope of coverage
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier
. . . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . priority 0..1 CodeableConcept Desired processing priority
Process Priority Codes ( Example )
. . . patient 0..1 Reference ( Patient ) The subject of the Products and Services
. . . serviced[x] 0..1 Estimated date or dates of Service
. . . . servicedDate date
. . . . servicedPeriod Period
. . . created 0..1 dateTime Creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author
. . . provider 0..1 Reference ( Practitioner ) Responsible practitioner organization 0..1 Reference | PractitionerRole ( | Organization ) Responsible organization practitioner
. . . insurer 0..1 Reference ( Organization ) Target
. . . facility 0..1 Reference ( Location ) Servicing Facility
. . . coverage 0..1 Reference ( Coverage ) Insurance or medical plan
. . . businessArrangement 0..1 string Business agreement
. . . benefitCategory 0..1 CodeableConcept Type of services covered
Benefit Category Codes ( Example )
. . . benefitSubCategory 0..1 CodeableConcept Detailed services covered within the type
Benefit SubCategory Codes ( Example )
. . . authorization 0..* BackboneElement Services which may require prior authorization
.... sequence 1..1 positiveInt Procedure sequence for reference
.... service 1..1 CodeableConcept Billing Code
USCLS Codes ( Example )
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per point
.... facility 0..1 Reference ( Location | Organization ) Servicing Facility
.... diagnosis 0..* BackboneElement List of Diagnosis
..... diagnosis[x] 0..1 Patient's diagnosis
ICD-10 Codes ( Example )
...... diagnosisCodeableConcept CodeableConcept
...... diagnosisReference Reference ( Condition )

doco Documentation for this format

UML Diagram ( Legend )

EligibilityRequest ( DomainResource ) The Response business identifier identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status ! » Immediate (STAT), best effort (NORMAL), deferred (DEFER) priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example) Process Priority ?? » Patient Resource patient : Reference [0..1] « Patient » The date or dates when the enclosed suite of services were performed or completed serviced[x] : Type [0..1] « date | Period » The date when this resource was created created : dateTime [0..1] Person who created the invoice/claim/pre-determination or pre-authorization enterer : Reference [0..1] « Practitioner | PractitionerRole » The practitioner who is responsible for the services rendered to the patient provider : Reference [0..1] « Practitioner | PractitionerRole | The organization which is responsible for the services rendered to the patient organization : Reference [0..1] Organization » The Insurer who is target of the request insurer : Reference [0..1] « Organization » Facility where the services were provided facility : Reference [0..1] « Location » Financial instrument by which payment information for health care coverage : Reference [0..1] « Coverage » The contract number of a business agreement which describes the terms and conditions businessArrangement : string [0..1] Dental, Vision, Medical, Pharmacy, Rehab etc benefitCategory : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? » Dental: basic, major, ortho; Vision exam, glasses, contacts; etc benefitSubCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? » Authorization Sequence of procedures which serves to order and provide a link sequence : positiveInt [1..1] A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) service : CodeableConcept [1..1] « Allowable service and product codes (Strength=Example) USCLS ?? » Item typification or modifiers codes, eg for 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 modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The fee for an addittional service or product or charge unitPrice : Money [0..1] Facility where the services were provided facility : Reference [0..1] « Location | Organization » Diagnosis The diagnosis diagnosis[x] : Type [0..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? » List of patient diagnosis for which care is sought diagnosis [0..*] A list of billable services for which an authorization prior to service delivery may be required by the payor authorization [0..*]

XML Template 

<

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

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <

 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->

 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <serviced[x]><!-- 0..1 date|Period Estimated date or dates of Service --></serviced[x]>
 <
 <</enterer>
 <</provider>
 <</organization>

 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></provider>

 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <coverage><!-- 0..1 Reference(Coverage) Insurance or medical plan --></coverage>
 <

 <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->

 <benefitCategory><!-- 0..1 CodeableConcept Type of services covered --></benefitCategory>
 <benefitSubCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></benefitSubCategory>
 <authorization>  <!-- 0..* Services which may require prior authorization -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <service><!-- 1..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <facility><!-- 0..1 Reference(Location|Organization) Servicing Facility --></facility>
  <diagnosis>  <!-- 0..* List of Diagnosis -->
   <diagnosis[x]><!-- 0..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  </diagnosis>
 </authorization>

</EligibilityRequest>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "EligibilityRequest",

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

  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "priority" : { CodeableConcept }, // Desired processing priority
  "patient" : { Reference(Patient) }, // The subject of the Products and Services

  // serviced[x]: Estimated date or dates of Service. One of these 2:
  ">",
  " },
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "servicedDate" : "<date>",
  "servicedPeriod" : { Period },
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "insurer" : { Reference(Organization) }, // Target
  "facility" : { Reference(Location) }, // Servicing Facility
  "coverage" : { Reference(Coverage) }, // Insurance or medical plan
  "businessArrangement" : "<string>", // Business agreement
  "benefitCategory" : { CodeableConcept }, // Type of services covered
  "benefitSubCategory" : { CodeableConcept }, // Detailed services covered within the type
  "authorization" : [{ // Services which may require prior authorization
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "service" : { CodeableConcept }, // R!  Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "facility" : { Reference(Location|Organization) }, // Servicing Facility
    "diagnosis" : [{ // List of Diagnosis
      // diagnosis[x]: Patient's diagnosis. One of these 2:

      "diagnosisCodeableConcept" : { CodeableConcept }
      "diagnosisReference" : { Reference(Condition) }
    }]
  }]

}

Turtle Template 

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


[ a fhir:EligibilityRequest;
  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:EligibilityRequest.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:EligibilityRequest.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityRequest.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:EligibilityRequest.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  # EligibilityRequest.serviced[x] : 0..1 Estimated date or dates of Service. One of these 2
    fhir:EligibilityRequest.servicedDate [ date ]
    fhir:EligibilityRequest.servicedPeriod [ Period ]
  fhir:EligibilityRequest.created [ dateTime ]; # 0..1 Creation date
  fhir:
  fhir:
  fhir:

  fhir:EligibilityRequest.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:EligibilityRequest.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner

  fhir:EligibilityRequest.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:EligibilityRequest.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:EligibilityRequest.coverage [ Reference(Coverage) ]; # 0..1 Insurance or medical plan
  fhir:EligibilityRequest.businessArrangement [ string ]; # 0..1 Business agreement
  fhir:EligibilityRequest.benefitCategory [ CodeableConcept ]; # 0..1 Type of services covered
  fhir:EligibilityRequest.benefitSubCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
  fhir:EligibilityRequest.authorization [ # 0..* Services which may require prior authorization
    fhir:EligibilityRequest.authorization.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:EligibilityRequest.authorization.service [ CodeableConcept ]; # 1..1 Billing Code
    fhir:EligibilityRequest.authorization.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:EligibilityRequest.authorization.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:EligibilityRequest.authorization.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:EligibilityRequest.authorization.facility [ Reference(Location|Organization) ]; # 0..1 Servicing Facility
    fhir:EligibilityRequest.authorization.diagnosis [ # 0..* List of Diagnosis
      # EligibilityRequest.authorization.diagnosis.diagnosis[x] : 0..1 Patient's diagnosis. One of these 2
        fhir:EligibilityRequest.authorization.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
        fhir:EligibilityRequest.authorization.diagnosis.diagnosisReference [ Reference(Condition) ]
    ], ...;
  ], ...;

]

Changes since DSTU2

EligibilityRequest
EligibilityRequest.status EligibilityRequest.enterer
  • Added Element Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole)
EligibilityRequest.priority EligibilityRequest.provider
  • Added Element Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization)
EligibilityRequest.patient EligibilityRequest.authorization
  • Added Element
EligibilityRequest.serviced[x] EligibilityRequest.authorization.sequence
  • Added Element
EligibilityRequest.enterer EligibilityRequest.authorization.service
  • Added Element
EligibilityRequest.insurer EligibilityRequest.authorization.modifier
  • Added Element
EligibilityRequest.facility EligibilityRequest.authorization.quantity
  • Added Element
EligibilityRequest.coverage EligibilityRequest.authorization.unitPrice
  • Added Element
EligibilityRequest.businessArrangement EligibilityRequest.authorization.facility
  • Added Element
EligibilityRequest.benefitCategory EligibilityRequest.authorization.diagnosis
  • Added Element
EligibilityRequest.benefitSubCategory EligibilityRequest.authorization.diagnosis.diagnosis[x]
  • Added Element
EligibilityRequest.ruleset deleted EligibilityRequest.originalRuleset deleted EligibilityRequest.target EligibilityRequest.organization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

 

Alternate definitions: Master Definition ( XML , + JSON ), , XML Schema / Schematron (for ) + JSON Schema , ShEx (for Turtle ) + see the extensions & the dependency analysis

13.2.2.1 Terminology Bindings

Path Definition Type Reference
EligibilityRequest.status A code specifying the state of the resource instance. Required Financial Resource Status Codes
EligibilityRequest.priority The timeliness with which processing is required: STAT, normal, Deferred Example Process Priority Codes
EligibilityRequest.benefitCategory Benefit categories such as: oral, medical, vision etc. Example Benefit Category Codes
EligibilityRequest.benefitSubCategory Benefit subcategories such as: oral-basic, major, glasses Example Benefit SubCategory Codes
EligibilityRequest.authorization.service Allowable service and product codes Example USCLS Codes
EligibilityRequest.authorization.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. Example Modifier type Codes
EligibilityRequest.authorization.diagnosis.diagnosis[x] ICD10 Diagnostic codes Example ICD-10 Codes

13.2.3 Search Parameters

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

Name Type Description Expression In Common
created date The creation date for the EOB EligibilityRequest.created
enterer reference The party who is responsible for the request EligibilityRequest.enterer
( Practitioner , PractitionerRole )
facility reference Facility responsible for the goods and services EligibilityRequest.facility
( Location )
identifier token The business identifier of the Eligibility EligibilityRequest.identifier
organization patient reference The reference to the providing organization patient EligibilityRequest.organization EligibilityRequest.patient
( Organization Patient )
patient provider reference The reference to the patient provider EligibilityRequest.patient EligibilityRequest.provider
( Patient Practitioner , Organization , PractitionerRole )
provider status reference token The reference to status of the provider EligibilityRequest EligibilityRequest.provider ( Practitioner ) EligibilityRequest.status