DSTU2 FHIR Release 3 (STU)

This page is part of the FHIR Specification (v1.0.2: DSTU (v3.0.2: STU 2). 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R3 R2 R3 R2

7.4 13.2 Resource EligibilityRequest - Content

This resource is marked as a draft .
Financial Management Work Group Maturity Level : 0 2   Trial Use Compartments : Not linked to any defined compartments Patient , Practitioner

This resource The EligibilityRequest provides the patient and insurance eligibility details from the coverage information to an insurer for them to respond, in the form of an EligibilityResponse, with information regarding a specified whether the stated coverage is valid and in-force and optionally some class to provide the insurance details of service. the policy.

7.4.1 13.2.1 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 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

This resource is referenced by eligibilityresponse

7.4.2 13.2.2 Resource Content

Structure

Σ Eligibility request Σ Resource version Σ Original version Σ Insurer Σ Responsible organization
Name Flags Card. Type Description & Constraints doco
. . EligibilityRequest 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
. . ruleset . status ?! Σ 0..1 Coding code active | cancelled | draft | entered-in-error
Ruleset Financial Resource Status Codes ( Example Required )
. . originalRuleset . priority 0..1 Coding CodeableConcept Desired processing priority
Ruleset Process Priority Codes ( Example )
. . created . patient Σ 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
. . target . enterer 0..1 Reference ( Organization Practitioner ) Author
. . . provider 0..1 Reference ( Practitioner ) Responsible practitioner
. . . organization Σ 0..1 Reference ( Organization ) Responsible organization
... 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 )

doco Documentation for this format

UML Diagram ( Legend )

EligibilityRequest ( DomainResource ) The Response business identifier identifier : Identifier [0..*] The version status of the style of resource contents. This should be mapped to instance (this element modifies the allowable profiles for this and supporting resources meaning of other elements) ruleset status : Coding 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 static and dynamic model to which contents conform, timeliness with which may be business version or standard/version. processing is required: STAT, normal, Deferred (Strength=Example) Ruleset Process Priority ?? » The style (standard) and version of the original material which was converted into this resource Patient Resource originalRuleset patient : Coding Reference [0..1] « Patient The static and dynamic model to which contents conform, which may be business version date or standard/version. (Strength=Example) dates when the enclosed suite of services were performed or completed Ruleset serviced[x] : Type [0..1] date | Period ?? » The date when this resource was created created : dateTime [0..1] The Insurer Person who is target of created the request invoice/claim/pre-determination or pre-authorization target enterer : Reference [0..1] « Organization Practitioner » The practitioner who is responsible for the services rendered to the patient provider : Reference [0..1] « Practitioner » 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 ??

XML Template 

<

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

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

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

</EligibilityRequest>

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

Changes since DSTU2

EligibilityRequest
EligibilityRequest.status
  • Added Element
EligibilityRequest.priority
  • Added Element
EligibilityRequest.patient
  • Added Element
EligibilityRequest.serviced[x]
  • Added Element
EligibilityRequest.enterer
  • Added Element
EligibilityRequest.insurer
  • Added Element
EligibilityRequest.facility
  • Added Element
EligibilityRequest.coverage
  • Added Element
EligibilityRequest.businessArrangement
  • Added Element
EligibilityRequest.benefitCategory
  • Added Element
EligibilityRequest.benefitSubCategory
  • Added Element
EligibilityRequest.ruleset
  • deleted
EligibilityRequest.originalRuleset
  • deleted
EligibilityRequest.target
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

Structure

Σ Eligibility request Σ Resource version Σ Original version Σ Insurer Σ Responsible organization
Name Flags Card. Type Description & Constraints doco
. . EligibilityRequest 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
. . ruleset . status ?! Σ 0..1 Coding code active | cancelled | draft | entered-in-error
Ruleset Financial Resource Status Codes ( Example Required )
. . originalRuleset . priority 0..1 Coding CodeableConcept Desired processing priority
Ruleset Process Priority Codes ( Example )
. . created . patient Σ 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
. . target . enterer 0..1 Reference ( Organization Practitioner ) Author
. . . provider 0..1 Reference ( Practitioner ) Responsible practitioner
. . . organization Σ 0..1 Reference ( Organization ) Responsible organization
... 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 )

doco Documentation for this format

UML Diagram ( Legend )

EligibilityRequest ( DomainResource ) The Response business identifier identifier : Identifier [0..*] The version status of the style of resource contents. This should be mapped to instance (this element modifies the allowable profiles for this and supporting resources meaning of other elements) ruleset status : Coding 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 static and dynamic model to which contents conform, timeliness with which may be business version or standard/version. processing is required: STAT, normal, Deferred (Strength=Example) Ruleset Process Priority ?? » The style (standard) and version of the original material which was converted into this resource Patient Resource originalRuleset patient : Coding Reference [0..1] « Patient The static and dynamic model to which contents conform, which may be business version date or standard/version. (Strength=Example) dates when the enclosed suite of services were performed or completed Ruleset serviced[x] : Type [0..1] date | Period ?? » The date when this resource was created created : dateTime [0..1] The Insurer Person who is target of created the request invoice/claim/pre-determination or pre-authorization target enterer : Reference [0..1] « Organization Practitioner » The practitioner who is responsible for the services rendered to the patient provider : Reference [0..1] « Practitioner » 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 ??

XML Template 

<

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

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

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

</EligibilityRequest>

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

  Changes since DSTU2

EligibilityRequest
EligibilityRequest.status
  • Added Element
EligibilityRequest.priority
  • Added Element
EligibilityRequest.patient
  • Added Element
EligibilityRequest.serviced[x]
  • Added Element
EligibilityRequest.enterer
  • Added Element
EligibilityRequest.insurer
  • Added Element
EligibilityRequest.facility
  • Added Element
EligibilityRequest.coverage
  • Added Element
EligibilityRequest.businessArrangement
  • Added Element
EligibilityRequest.benefitCategory
  • Added Element
EligibilityRequest.benefitSubCategory
  • Added Element
EligibilityRequest.ruleset
  • deleted
EligibilityRequest.originalRuleset
  • deleted
EligibilityRequest.target
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

 

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

7.4.2.1 13.2.2.1 Terminology Bindings

EligibilityRequest.ruleset EligibilityRequest.originalRuleset
Path Definition Type Reference
EligibilityRequest.status A code specifying the state of the resource instance. Required Financial Resource Status Codes
EligibilityRequest.priority The static and dynamic model to which contents conform, timeliness with which may be business version or standard/version. processing is required: STAT, normal, Deferred Example Ruleset 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

7.4.3 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 Paths 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 )
facility reference Facility responsible for the goods and services EligibilityRequest.facility
( Location )
identifier token The business identifier of the Eligibility EligibilityRequest.identifier
organization reference The reference to the providing organization EligibilityRequest.organization
( Organization )
patient reference The reference to the patient EligibilityRequest.patient
( Patient )
provider reference The reference to the provider EligibilityRequest.provider
( Practitioner )