R3 Conversions

13.2 4.3.2.96 Resource CoverageEligibilityRequest - Content CodeSystem http://hl7.org/fhir/device-association-status

Security Category : Patient Coverage Provides the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services.

Financial Management Orders and Observations Work Group

Maturity Level : 2

Trial Use

Compartments : Patient , Practitioner The CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, 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 CoverageEligibilityRequest makes a request of an insurer asking them to provide, in the form of an CoverageEligibilityResponse, information regarding: (validation) whether the specified coverage(s) is valid and in-force; (discovery) what coverages the insurer has for the specified patient; (benefits) the benefits provided under the coverage; whether benefits exist under the specified coverage(s) for specified classes of services and products; and (auth-requirements) whether preauthorization is required, and if so what information may be required in that preauthorization, for the specified service classes or services. The CoverageEligibilityRequest resource is a "event" resource from a FHIR workflow perspective - see Workflow Event. 13.2.1.1 Additional Information Additional information regarding electronic coverage eligibility content and usage may be found at: Financial Resource Status Lifecycle : how .status is used in the financial resources. Subrogation : how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages. Coordination of Benefit : how eClaims may handle multiple patient insurance coverages. Batches : how eClaims may handle batches of eligibility, claims and responses. Attachments and Supporting Information Use Context : how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This includes how payors how request additional supporting information from providers. 13.2.2 Boundaries and Relationships CoverageEligibilityRequest should be used when requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage. The Claim resource should be used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient. The Coverage resource contains the information typically found on the health insurance card for an individual used to identify the covered individual to the insurer and is referred to by the CoverageEligibilityRequest. The eClaim domain includes a number of related resources CoverageEligibilityRequest Patient and insurance coverage information provided to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy. Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested. Country: World, Country: World

This resource is referenced by CoverageEligibilityResponse 13.2.3 Resource Content

• Structure Narrative
UML
• XML
• JSON
Turtle
• R3 Diff TTL
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Structure Name Flags Card. Type Description & Constraints status ?! Σ 1..1 code Period created Σ 1..1 dateTime Creation date enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author provider 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the request insurer Σ 1..1 Reference ( Organization ) Coverage issuer facility 0..1 Reference ( Location ) Servicing facility supportingInfo 0..* BackboneElement Supporting information sequence 1..1 positiveInt Information instance identifier information 1..1 Reference ( Any ) Data to be provided appliesToAll 0..1 boolean Applies to all items insurance 0..* BackboneElement Patient insurance information focal 0..1 boolean Applicable coverage coverage 1..1 Reference ( Coverage ) Insurance information businessArrangement 0..1 string Additional provider contract number item 0..* BackboneElement Item to be evaluated for eligibiity supportingInfoSequence 0..* positiveInt Applicable exception or supporting information category 0..1 CodeableConcept Benefit classification Benefit Category Codes ( Example ) productOrService 0..1 CodeableConcept Billing, service, product, or drug code USCLS Codes ( Example ) modifier 0..* CodeableConcept Product or service billing modifiers Modifier type Codes ( Example ) provider 0..1 Reference ( Practitioner | PractitionerRole ) Perfoming practitioner quantity 0..1 SimpleQuantity Count of products or services unitPrice 0..1 Money Fee, charge or cost per item facility 0..1 Reference ( Location | Organization ) Servicing facility diagnosis 0..* BackboneElement Applicable diagnosis diagnosis[x] CodeableConcept diagnosisReference Reference ( Condition ) detail 0..* Reference ( Any ) Product or service details Documentation for this format

Official URL : http://hl7.org/fhir/device-association-status CoverageEligibilityRequest TU DomainResource CoverageEligibilityRequest resource Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension identifier 0..*				Identifier Business Identifier for coverage eligiblity request Version : 5.0.0-snapshot3
active | cancelled | draft | entered-in-error Financial Resource Status Codes ( Required ) priority 0..1 CodeableConcept Desired processing priority Process Priority Codes ( Example ) purpose Σ 1..* code auth-requirements | benefits | discovery | validation EligibilityRequestPurpose ( Required ) patient Σ 1..1 Reference ( Patient ) Intended recipient of products and services serviced[x] 0..1 Estimated date or dates as of service servicedDate date 2021-01-05				servicedPeriod Computable Name : FHIRDeviceAssociationStatus
Flags : CaseSensitive, Complete. All codes ValueSet: FHIRDeviceAssociationStatus				0..1 Nature of illness or problem ICD-10 Codes ( Example ) diagnosisCodeableConcept OID : 2.16.840.1.113883.4.642.4.2049

UML Diagram ( Legend ) CoverageEligibilityRequest ( DomainResource ) A unique identifier assigned to this coverage eligiblity request identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required) FinancialResourceStatusCodes ! » When the requestor expects the processor to complete processing priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example) ProcessPriorityCodes ?? » This Code 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 purpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required) EligibilityRequestPurpose ! » The party who is the beneficiary of the supplied coverage and for whom eligibility is sought patient : Reference [1..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 [1..1] Person who created the request enterer : Reference [0..1] « Practitioner | PractitionerRole » The provider which is responsible for the request provider : Reference [0..1] « Practitioner | PractitionerRole | Organization » The Insurer who issued the coverage in question and is the recipient of the request insurer : Reference [1..1] « Organization » Facility where the services are intended to be provided facility : Reference [0..1] « Location » SupportingInformation A number to uniquely identify supporting information entries sequence : positiveInt [1..1] Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data information : Reference [1..1] « Any » The supporting materials are applicable for all detail items, product/servce categories and specific billing codes appliesToAll : boolean [0..1] Insurance A flag to indicate that this Coverage system is to be used for evaluation of this request when set to true focal : boolean [0..1] Reference 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 coverage : Reference [1..1] « Coverage » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] Details Exceptions, special conditions and supporting information applicable for this service or product line supportingInfoSequence : positiveInt following value sets:

• ValueSet: FHIRDeviceAssociationStatus [0..*] Code to identify the general type (The association status of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) BenefitCategoryCodes ?? » This contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service 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) ModifierTypeCodes ?? » The practitioner who is responsible for the product or service to be rendered to the patient provider : Reference [0..1] « Practitioner | PractitionerRole » device.)

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The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1]

4.3.2.96.1 Definition The amount charged to the patient by the provider for a single unit unitPrice : Money [0..1] Facility where the services will be provided facility : Reference [0..1] « Location | Organization » The plan/proposal/order describing the proposed service in detail detail : Reference [0..*] « Any » Diagnosis

The nature association status of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type [0..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes ?? » Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Financial instruments for reimbursement for the health care products and services insurance [0..*] device.

Patient diagnosis for which care is sought diagnosis

[0..*] 4.3.2.96.2 Content Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor item [0..*]

UML Diagram ( Legend )  

CoverageEligibilityRequest ( DomainResource ) A unique identifier assigned to this coverage eligiblity request identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required) FinancialResourceStatusCodes ! » When the requestor expects the processor to complete processing priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example) ProcessPriorityCodes ?? » Code 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 purpose : code [1..*] « A code specifying the types of information being requested. (Strength=Required) EligibilityRequestPurpose ! » The party who is the beneficiary of the supplied coverage and for whom eligibility is sought patient : Reference [1..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 [1..1] Person who created the request enterer : Reference [0..1] « Practitioner | PractitionerRole » The provider which is responsible for the request provider : Reference [0..1] « Practitioner | PractitionerRole | Organization » The Insurer who issued the coverage in question and is the recipient of the request insurer : Reference [1..1] « Organization » Facility where the services are intended to be provided facility : Reference [0..1] « Location » SupportingInformation A number to uniquely identify supporting information entries sequence : positiveInt [1..1] Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data information : Reference [1..1] « Any » The supporting materials are applicable for all detail items, product/servce categories and specific billing codes appliesToAll : boolean [0..1] Insurance A flag to indicate that this Coverage is to be used for evaluation of this request when set to true focal : boolean [0..1] Reference 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 coverage : Reference [1..1] « Coverage » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] Details Exceptions, special conditions and supporting information applicable for this service or product line supportingInfoSequence : positiveInt [0..*] Code to identify

See the general type full registry of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) BenefitCategoryCodes ?? » This contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service 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) ModifierTypeCodes ?? » The practitioner who is responsible for the product or service to be rendered to the patient provider : Reference [0..1] « Practitioner | PractitionerRole » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The amount charged to the patient by the provider for a single unit unitPrice : Money [0..1] Facility where the services will be provided facility : Reference [0..1] « Location | Organization » The plan/proposal/order describing the proposed service in detail detail : Reference [0..*] « Any systems » Diagnosis The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type [0..1] « CodeableConcept | Reference ( Condition ); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes ?? » Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Financial instruments for reimbursement for the health care products and services insurance [0..*] Patient diagnosis for which care is sought diagnosis [0..*] Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor item [0..*] XML Template < <!-- from --> <!-- from --> <</identifier> < <</priority> < <</patient> <</serviced[x]> < <</enterer> <</provider> <</insurer> <</facility> < < <</information> < </supportingInfo> < < <</coverage> < </insurance> < < <</category> <</productOrService> <</modifier> <</provider> <</quantity> <</unitPrice> <</facility> < <</diagnosis[x]> </diagnosis> <</detail> </item> </CoverageEligibilityRequest> JSON Template { "resourceType" : "", // from // from " " " " " ">", " }, " " " " " " " " " }], " " " " }], " " " " " " " " " " " } " } }], " }] } Turtle Template @prefix fhir: <http://hl7.org/fhir/> . [ a fhir:; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from # from fhir: fhir: fhir: fhir: fhir: # . One of these 2 fhir: ] fhir: ] fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: ], ...; fhir: fhir: fhir: fhir: ], ...; fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: # . One of these 2 fhir: ] fhir:) ] ], ...; fhir: ], ...; ] Changes since Release 3 This resource did not exist in Release 2 This analysis is available as XML or JSON . See R3 <--> R4 Conversion Maps (status = Not Mapped)   part of FHIR.

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See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions & Explanation of the dependency analysis columns that may appear on this page:

13.2.3.1 Terminology Bindings Path Definition Type Reference CoverageEligibilityRequest.status A code specifying the state of the resource instance.

Required FinancialResourceStatusCodes CoverageEligibilityRequest.priority The timeliness with which processing is required: STAT, normal, Deferred. Level	Example ProcessPriorityCodes CoverageEligibilityRequest.purpose A few code lists that FHIR defines are hierarchical - each code specifying the types of information being requested. Required EligibilityRequestPurpose CoverageEligibilityRequest.item.category Benefit categories such as: oral, medical, vision etc. Example BenefitCategoryCodes CoverageEligibilityRequest.item.productOrService Allowable service and product codes. Example USCLSCodes CoverageEligibilityRequest.item.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 ModifierTypeCodes CoverageEligibilityRequest.item.diagnosis.diagnosis[x] ICD10 Diagnostic codes. Example ICD-10Codes 13.2.4 Search Parameters Search parameters for this resource. The common parameters also apply. assigned a level. See Searching Code System for more information about searching in REST, messaging, and services. Name Type Description Expression In Common further information.
created date Source	The creation date for source of the EOB CoverageEligibilityRequest.created definition of the code (when the value set draws in codes defined elsewhere)
enterer reference Code	The party who code (used as the code in the resource instance). If the code is responsible for in italics, this indicates that the request CoverageEligibilityRequest.enterer ( Practitioner , PractitionerRole ) code is not selectable ('Abstract')
facility reference Display	Facility responsible for The display (used in the goods and services CoverageEligibilityRequest.facility ( Location display element of a Coding ) ). If there is no display, implementers should not simply display the code, but map the concept into their application
identifier token Definition	The business identifier An explanation of the Eligibility CoverageEligibilityRequest.identifier patient reference The reference to meaning of the patient CoverageEligibilityRequest.patient ( Patient ) concept
provider reference Comments	The reference Additional notes about how to use the provider CoverageEligibilityRequest.provider ( Practitioner , Organization , PractitionerRole ) status token The status of the EligibilityRequest CoverageEligibilityRequest.status code