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

13.3 Resource EligibilityResponse - Content

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

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

13.3.1 Scope and Usage

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.

For Balloters: The optional Authorization subclass has been addded for comment ballot review. The EligibilityResponse would return a boolean indicating whether pre-authorization is required and an optional text element woud convey and special instructions for each of the billable services provided in the EligibilityRequest.

13.3.2 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
. . EligibilityResponse TU DomainResource EligibilityResponse resource
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 )
. . . created 0..1 dateTime Creation date
. . . requestProvider 0..1 Reference ( Practitioner ) Responsible practitioner requestOrganization 0..1 Reference | PractitionerRole ( | Organization ) Responsible organization practitioner
. . . request 0..1 Reference ( EligibilityRequest ) Eligibility reference
. . . outcome 0..1 CodeableConcept code queued | complete | error | partial
RemittanceOutcome ( Required )
. . . disposition 0..1 string Disposition Message
. . . insurer 0..1 Reference ( Organization ) Insurer issuing the coverage
. . . inforce 0..1 boolean Coverage inforce indicator
. . . insurance 0..* BackboneElement Details by insurance coverage
. . . . coverage 0..1 Reference ( Coverage ) Updated Coverage details
. . . . contract 0..1 Reference ( Contract ) Contract details
. . . . benefitBalance 0..* BackboneElement Benefits by Category
. . . . . category 1..1 CodeableConcept Type of services covered
Benefit Category Codes ( Example )
. . . . . subCategory 0..1 CodeableConcept Detailed services covered within the type
Benefit SubCategory Codes ( Example )
. . . . . excluded 0..1 boolean Excluded from the plan
. . . . . name 0..1 string Short name for the benefit
. . . . . description 0..1 string Description of the benefit or services covered
. . . . . network 0..1 CodeableConcept In or out of network
Network Type Codes ( Example )
. . . . . unit 0..1 CodeableConcept Individual or family
Unit Type Codes ( Example )
. . . . . term 0..1 CodeableConcept Annual or lifetime
Benefit Term Codes ( Example )
. . . . . financial 0..* BackboneElement Benefit Summary
. . . . . . type 1..1 CodeableConcept Deductable, visits, benefit amount
Benefit Type Codes ( Example )
. . . . . . allowed[x] 0..1 Benefits allowed
. . . . . . . allowedUnsignedInt unsignedInt
. . . . . . . allowedString string
. . . . . . . allowedMoney Money
. . . . . . used[x] 0..1 Benefits used
. . . . . . . usedUnsignedInt unsignedInt
. . . . . . . usedMoney Money
. . . preAuthRef 0..1 string Pre-Authorization/Determination Reference
... authorization 0..* BackboneElement Services which may require prior authorization
.... authorizationSequence 1..1 positiveInt Procedure sequence for reference
.... required 1..1 boolean Authorization required flag
.... note 0..* Annotation Comments and instructions
. . . form 0..1 CodeableConcept Printed Form Identifier
Form Codes ( Example )
. . . error 0..* BackboneElement Processing errors
. . . . code 1..1 CodeableConcept Error code detailing processing issues
Adjudication Error Codes ( Example )

doco Documentation for this format

UML Diagram ( Legend )

EligibilityResponse ( 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 ! » The date when the enclosed suite of services were performed or completed created : dateTime [0..1] The practitioner who is responsible for the services rendered to the patient requestProvider : Reference [0..1] « Practitioner | PractitionerRole | The organization which is responsible for the services rendered to the patient requestOrganization : Reference [0..1] Organization » Original request resource reference request : Reference [0..1] « EligibilityRequest » Transaction status: error, complete outcome : CodeableConcept code [0..1] « The outcome of the processing. (Strength=Required) RemittanceOutcome ! » A description of the status of the adjudication disposition : string [0..1] The Insurer who produced this adjudicated response insurer : 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] A reference from the Insurer to which these services pertain preAuthRef : string [0..1] The form to be used for printing the content form : CodeableConcept [0..1] « The forms codes. (Strength=Example) Form ?? » Insurance A suite of updated or additional Coverages from the Insurer coverage : Reference [0..1] « Coverage » The contract resource which may provide more detailed information contract : Reference [0..1] « Contract » Benefits Dental, Vision, Medical, Pharmacy, Rehab etc category : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? » Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? » True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage excluded : boolean [0..1] 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 : CodeableConcept [0..1] « Code to classify in or out of network services (Strength=Example) Network Type ?? » Unit designation: individual or family unit : CodeableConcept [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 : CodeableConcept [0..1] « Coverage unit - annual, lifetime (Strength=Example) Benefit Term ?? » Benefit Deductable, visits, benefit amount type : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? » Benefits allowed allowed[x] : Type [0..1] « unsignedInt | string | Money » Benefits used used[x] : Type [0..1] « unsignedInt | Money » Authorization Sequence of procedures which serves to order and provide a link authorizationSequence : positiveInt [1..1] A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service delivery required : boolean [1..1] Any comments regarding information or actions assciated with the pre-authorization note : Annotation [0..*] Errors An error code,from a specified code system, which details why the eligibility check could not be performed code : CodeableConcept [1..1] « The error codes for adjudication processing. (Strength=Example) Adjudication Error ?? » Benefits Used to date financial [0..*] Benefits and optionally current balances by Category benefitBalance [0..*] The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer insurance [0..*] A list of billable services for which an authorization prior to service delivery may be required by the payor authorization [0..*] Mutually exclusive with Services Provided (Item) error [0..*]

XML Template 

<

<EligibilityResponse 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>
 <
 <
 <</requestProvider>
 <</requestOrganization>

 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></requestProvider>

 <request><!-- 0..1 Reference(EligibilityRequest) Eligibility reference --></request>
 <</outcome>
 <

 <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->

 <insurer><!-- 0..1 Reference(Organization) Insurer issuing the coverage --></insurer>
 <

 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->

 <insurance>  <!-- 0..* Details by insurance coverage -->
  <coverage><!-- 0..1 Reference(Coverage) Updated Coverage details --></coverage>
  <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
  <benefitBalance>  <!-- 0..* Benefits by Category -->
   <category><!-- 1..1 CodeableConcept Type of services covered --></category>
   <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></subCategory>
   <
   <
   <

   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->

   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <financial>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
   </financial>
  </benefitBalance>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference -->
 <authorization>  <!-- 0..* Services which may require prior authorization -->
  <authorizationSequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <required value="[boolean]"/><!-- 1..1 Authorization required flag -->
  <note><!-- 0..* Annotation Comments and instructions --></note>
 </authorization>

 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</EligibilityResponse>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "EligibilityResponse",

  // 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
  "created" : "<dateTime>", // Creation date
  "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "request" : { Reference(EligibilityRequest) }, // Eligibility reference
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer issuing the coverage
  "inforce" : <boolean>, // Coverage inforce indicator
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "benefitBalance" : [{ // Benefits by Category
      "category" : { CodeableConcept }, // R!  Type of services covered
      "subCategory" : { CodeableConcept }, // Detailed services covered within the type
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "financial" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount

        // allowed[x]: Benefits allowed. One of these 3:
        ">",
        ">",
        " },

        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },

        // used[x]: Benefits used. One of these 2:
        ">"
        " }

        "usedUnsignedInt" : "<unsignedInt>"
        "usedMoney" : { Money }

      }]
    }]
  }],
  "
  "
    "

  "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference
  "authorization" : [{ // Services which may require prior authorization
    "authorizationSequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "required" : <boolean>, // R!  Authorization required flag
    "note" : [{ Annotation }] // Comments and instructions
  }],
  "form" : { CodeableConcept }, // Printed Form Identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // 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 ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:
  fhir:

  fhir:EligibilityResponse.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner

  fhir:EligibilityResponse.request [ Reference(EligibilityRequest) ]; # 0..1 Eligibility reference
  fhir:

  fhir:EligibilityResponse.outcome [ code ]; # 0..1 queued | complete | error | partial

  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer issuing the coverage
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce indicator
  fhir:EligibilityResponse.insurance [ # 0..* Details by insurance coverage
    fhir:EligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 0..1 Updated Coverage details
    fhir:EligibilityResponse.insurance.contract [ Reference(Contract) ]; # 0..1 Contract details
    fhir:EligibilityResponse.insurance.benefitBalance [ # 0..* Benefits by Category
      fhir:EligibilityResponse.insurance.benefitBalance.category [ CodeableConcept ]; # 1..1 Type of services covered
      fhir:EligibilityResponse.insurance.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
      fhir:EligibilityResponse.insurance.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:EligibilityResponse.insurance.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
      fhir:EligibilityResponse.insurance.benefitBalance.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:EligibilityResponse.insurance.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:EligibilityResponse.insurance.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:EligibilityResponse.insurance.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:EligibilityResponse.insurance.benefitBalance.financial [ # 0..* Benefit Summary
        fhir:EligibilityResponse.insurance.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Deductable, visits, benefit amount
        # EligibilityResponse.insurance.benefitBalance.financial.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedString [ string ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedMoney [ Money ]
        # EligibilityResponse.insurance.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedMoney [ Money ]
      ], ...;
    ], ...;
  ], ...;
  fhir:EligibilityResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference
  fhir:EligibilityResponse.authorization [ # 0..* Services which may require prior authorization
    fhir:EligibilityResponse.authorization.authorizationSequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:EligibilityResponse.authorization.required [ boolean ]; # 1..1 Authorization required flag
    fhir:EligibilityResponse.authorization.note [ Annotation ], ... ; # 0..* Comments and instructions
  ], ...;

  fhir:EligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:EligibilityResponse.error [ # 0..* Processing errors
    fhir:EligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since DSTU2 R3

EligibilityResponse.status
EligibilityResponse Added Element
EligibilityResponse.outcome EligibilityResponse.requestProvider
  • Type changed from code Reference(Practitioner) to CodeableConcept EligibilityResponse.insurer Added Element EligibilityResponse.inforce Added Element EligibilityResponse.insurance Added Element EligibilityResponse.insurance.coverage Added Element EligibilityResponse.insurance.contract Added Element EligibilityResponse.insurance.benefitBalance Added Element EligibilityResponse.insurance.benefitBalance.category Added Element EligibilityResponse.insurance.benefitBalance.subCategory Added Element EligibilityResponse.insurance.benefitBalance.excluded Added Element EligibilityResponse.insurance.benefitBalance.name Added Element EligibilityResponse.insurance.benefitBalance.description Added Element EligibilityResponse.insurance.benefitBalance.network Added Element EligibilityResponse.insurance.benefitBalance.unit Added Element EligibilityResponse.insurance.benefitBalance.term Added Element EligibilityResponse.insurance.benefitBalance.financial Added Element Reference(Practitioner|PractitionerRole|Organization)
EligibilityResponse.insurance.benefitBalance.financial.type EligibilityResponse.outcome
  • Added Element Type changed from CodeableConcept to code
EligibilityResponse.insurance.benefitBalance.financial.allowed[x] EligibilityResponse.preAuthRef
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.used[x] EligibilityResponse.authorization
  • Added Element
EligibilityResponse.form EligibilityResponse.authorization.authorizationSequence
  • Added Element
EligibilityResponse.error EligibilityResponse.authorization.required
  • Added Element
EligibilityResponse.error.code EligibilityResponse.authorization.note
  • Added Element
EligibilityResponse.ruleset deleted EligibilityResponse.originalRuleset deleted EligibilityResponse.organization EligibilityResponse.requestOrganization
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

Structure

Name Flags Card. Type Description & Constraints doco
. . EligibilityResponse TU DomainResource EligibilityResponse resource
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 )
. . . created 0..1 dateTime Creation date
. . . requestProvider 0..1 Reference ( Practitioner ) Responsible practitioner requestOrganization 0..1 Reference | PractitionerRole ( | Organization ) Responsible organization practitioner
. . . request 0..1 Reference ( EligibilityRequest ) Eligibility reference
. . . outcome 0..1 CodeableConcept code queued | complete | error | partial
RemittanceOutcome ( Required )
. . . disposition 0..1 string Disposition Message
. . . insurer 0..1 Reference ( Organization ) Insurer issuing the coverage
. . . inforce 0..1 boolean Coverage inforce indicator
. . . insurance 0..* BackboneElement Details by insurance coverage
. . . . coverage 0..1 Reference ( Coverage ) Updated Coverage details
. . . . contract 0..1 Reference ( Contract ) Contract details
. . . . benefitBalance 0..* BackboneElement Benefits by Category
. . . . . category 1..1 CodeableConcept Type of services covered
Benefit Category Codes ( Example )
. . . . . subCategory 0..1 CodeableConcept Detailed services covered within the type
Benefit SubCategory Codes ( Example )
. . . . . excluded 0..1 boolean Excluded from the plan
. . . . . name 0..1 string Short name for the benefit
. . . . . description 0..1 string Description of the benefit or services covered
. . . . . network 0..1 CodeableConcept In or out of network
Network Type Codes ( Example )
. . . . . unit 0..1 CodeableConcept Individual or family
Unit Type Codes ( Example )
. . . . . term 0..1 CodeableConcept Annual or lifetime
Benefit Term Codes ( Example )
. . . . . financial 0..* BackboneElement Benefit Summary
. . . . . . type 1..1 CodeableConcept Deductable, visits, benefit amount
Benefit Type Codes ( Example )
. . . . . . allowed[x] 0..1 Benefits allowed
. . . . . . . allowedUnsignedInt unsignedInt
. . . . . . . allowedString string
. . . . . . . allowedMoney Money
. . . . . . used[x] 0..1 Benefits used
. . . . . . . usedUnsignedInt unsignedInt
. . . . . . . usedMoney Money
. . . preAuthRef 0..1 string Pre-Authorization/Determination Reference
... authorization 0..* BackboneElement Services which may require prior authorization
.... authorizationSequence 1..1 positiveInt Procedure sequence for reference
.... required 1..1 boolean Authorization required flag
.... note 0..* Annotation Comments and instructions
. . . form 0..1 CodeableConcept Printed Form Identifier
Form Codes ( Example )
. . . error 0..* BackboneElement Processing errors
. . . . code 1..1 CodeableConcept Error code detailing processing issues
Adjudication Error Codes ( Example )

doco Documentation for this format

UML Diagram ( Legend )

EligibilityResponse ( 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 ! » The date when the enclosed suite of services were performed or completed created : dateTime [0..1] The practitioner who is responsible for the services rendered to the patient requestProvider : Reference [0..1] « Practitioner | PractitionerRole | The organization which is responsible for the services rendered to the patient requestOrganization : Reference [0..1] Organization » Original request resource reference request : Reference [0..1] « EligibilityRequest » Transaction status: error, complete outcome : CodeableConcept code [0..1] « The outcome of the processing. (Strength=Required) RemittanceOutcome ! » A description of the status of the adjudication disposition : string [0..1] The Insurer who produced this adjudicated response insurer : 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] A reference from the Insurer to which these services pertain preAuthRef : string [0..1] The form to be used for printing the content form : CodeableConcept [0..1] « The forms codes. (Strength=Example) Form ?? » Insurance A suite of updated or additional Coverages from the Insurer coverage : Reference [0..1] « Coverage » The contract resource which may provide more detailed information contract : Reference [0..1] « Contract » Benefits Dental, Vision, Medical, Pharmacy, Rehab etc category : CodeableConcept [1..1] « Benefit categories such as: oral, medical, vision etc. (Strength=Example) Benefit Category ?? » Dental: basic, major, ortho; Vision exam, glasses, contacts; etc subCategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? » True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage excluded : boolean [0..1] 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 : CodeableConcept [0..1] « Code to classify in or out of network services (Strength=Example) Network Type ?? » Unit designation: individual or family unit : CodeableConcept [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 : CodeableConcept [0..1] « Coverage unit - annual, lifetime (Strength=Example) Benefit Term ?? » Benefit Deductable, visits, benefit amount type : CodeableConcept [1..1] « Deductable, visits, co-pay, etc. (Strength=Example) Benefit Type ?? » Benefits allowed allowed[x] : Type [0..1] « unsignedInt | string | Money » Benefits used used[x] : Type [0..1] « unsignedInt | Money » Authorization Sequence of procedures which serves to order and provide a link authorizationSequence : positiveInt [1..1] A boolean flag indicating whether a prior authorization or pre-authorization is required prior to actual service delivery required : boolean [1..1] Any comments regarding information or actions assciated with the pre-authorization note : Annotation [0..*] Errors An error code,from a specified code system, which details why the eligibility check could not be performed code : CodeableConcept [1..1] « The error codes for adjudication processing. (Strength=Example) Adjudication Error ?? » Benefits Used to date financial [0..*] Benefits and optionally current balances by Category benefitBalance [0..*] The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer insurance [0..*] A list of billable services for which an authorization prior to service delivery may be required by the payor authorization [0..*] Mutually exclusive with Services Provided (Item) error [0..*]

XML Template 

<

<EligibilityResponse 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>
 <
 <
 <</requestProvider>
 <</requestOrganization>

 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></requestProvider>

 <request><!-- 0..1 Reference(EligibilityRequest) Eligibility reference --></request>
 <</outcome>
 <

 <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->

 <insurer><!-- 0..1 Reference(Organization) Insurer issuing the coverage --></insurer>
 <

 <inforce value="[boolean]"/><!-- 0..1 Coverage inforce indicator -->

 <insurance>  <!-- 0..* Details by insurance coverage -->
  <coverage><!-- 0..1 Reference(Coverage) Updated Coverage details --></coverage>
  <contract><!-- 0..1 Reference(Contract) Contract details --></contract>
  <benefitBalance>  <!-- 0..* Benefits by Category -->
   <category><!-- 1..1 CodeableConcept Type of services covered --></category>
   <subCategory><!-- 0..1 CodeableConcept Detailed services covered within the type --></subCategory>
   <
   <
   <

   <excluded value="[boolean]"/><!-- 0..1 Excluded from the plan -->
   <name value="[string]"/><!-- 0..1 Short name for the benefit -->
   <description value="[string]"/><!-- 0..1 Description of the benefit or services covered -->

   <network><!-- 0..1 CodeableConcept In or out of network --></network>
   <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
   <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
   <financial>  <!-- 0..* Benefit Summary -->
    <type><!-- 1..1 CodeableConcept Deductable, visits, benefit amount --></type>
    <allowed[x]><!-- 0..1 unsignedInt|string|Money Benefits allowed --></allowed[x]>
    <used[x]><!-- 0..1 unsignedInt|Money Benefits used --></used[x]>
   </financial>
  </benefitBalance>
 </insurance>
 <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference -->
 <authorization>  <!-- 0..* Services which may require prior authorization -->
  <authorizationSequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <required value="[boolean]"/><!-- 1..1 Authorization required flag -->
  <note><!-- 0..* Annotation Comments and instructions --></note>
 </authorization>

 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <error>  <!-- 0..* Processing errors -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</EligibilityResponse>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "EligibilityResponse",

  // 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
  "created" : "<dateTime>", // Creation date
  "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "request" : { Reference(EligibilityRequest) }, // Eligibility reference
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "insurer" : { Reference(Organization) }, // Insurer issuing the coverage
  "inforce" : <boolean>, // Coverage inforce indicator
  "insurance" : [{ // Details by insurance coverage
    "coverage" : { Reference(Coverage) }, // Updated Coverage details
    "contract" : { Reference(Contract) }, // Contract details
    "benefitBalance" : [{ // Benefits by Category
      "category" : { CodeableConcept }, // R!  Type of services covered
      "subCategory" : { CodeableConcept }, // Detailed services covered within the type
      "excluded" : <boolean>, // Excluded from the plan
      "name" : "<string>", // Short name for the benefit
      "description" : "<string>", // Description of the benefit or services covered
      "network" : { CodeableConcept }, // In or out of network
      "unit" : { CodeableConcept }, // Individual or family
      "term" : { CodeableConcept }, // Annual or lifetime
      "financial" : [{ // Benefit Summary
        "type" : { CodeableConcept }, // R!  Deductable, visits, benefit amount

        // allowed[x]: Benefits allowed. One of these 3:
        ">",
        ">",
        " },

        "allowedUnsignedInt" : "<unsignedInt>",
        "allowedString" : "<string>",
        "allowedMoney" : { Money },

        // used[x]: Benefits used. One of these 2:
        ">"
        " }

        "usedUnsignedInt" : "<unsignedInt>"
        "usedMoney" : { Money }

      }]
    }]
  }],
  "
  "
    "

  "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference
  "authorization" : [{ // Services which may require prior authorization
    "authorizationSequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "required" : <boolean>, // R!  Authorization required flag
    "note" : [{ Annotation }] // Comments and instructions
  }],
  "form" : { CodeableConcept }, // Printed Form Identifier
  "error" : [{ // Processing errors
    "code" : { CodeableConcept } // 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 ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:EligibilityResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:
  fhir:

  fhir:EligibilityResponse.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner

  fhir:EligibilityResponse.request [ Reference(EligibilityRequest) ]; # 0..1 Eligibility reference
  fhir:

  fhir:EligibilityResponse.outcome [ code ]; # 0..1 queued | complete | error | partial

  fhir:EligibilityResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:EligibilityResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer issuing the coverage
  fhir:EligibilityResponse.inforce [ boolean ]; # 0..1 Coverage inforce indicator
  fhir:EligibilityResponse.insurance [ # 0..* Details by insurance coverage
    fhir:EligibilityResponse.insurance.coverage [ Reference(Coverage) ]; # 0..1 Updated Coverage details
    fhir:EligibilityResponse.insurance.contract [ Reference(Contract) ]; # 0..1 Contract details
    fhir:EligibilityResponse.insurance.benefitBalance [ # 0..* Benefits by Category
      fhir:EligibilityResponse.insurance.benefitBalance.category [ CodeableConcept ]; # 1..1 Type of services covered
      fhir:EligibilityResponse.insurance.benefitBalance.subCategory [ CodeableConcept ]; # 0..1 Detailed services covered within the type
      fhir:EligibilityResponse.insurance.benefitBalance.excluded [ boolean ]; # 0..1 Excluded from the plan
      fhir:EligibilityResponse.insurance.benefitBalance.name [ string ]; # 0..1 Short name for the benefit
      fhir:EligibilityResponse.insurance.benefitBalance.description [ string ]; # 0..1 Description of the benefit or services covered
      fhir:EligibilityResponse.insurance.benefitBalance.network [ CodeableConcept ]; # 0..1 In or out of network
      fhir:EligibilityResponse.insurance.benefitBalance.unit [ CodeableConcept ]; # 0..1 Individual or family
      fhir:EligibilityResponse.insurance.benefitBalance.term [ CodeableConcept ]; # 0..1 Annual or lifetime
      fhir:EligibilityResponse.insurance.benefitBalance.financial [ # 0..* Benefit Summary
        fhir:EligibilityResponse.insurance.benefitBalance.financial.type [ CodeableConcept ]; # 1..1 Deductable, visits, benefit amount
        # EligibilityResponse.insurance.benefitBalance.financial.allowed[x] : 0..1 Benefits allowed. One of these 3
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedString [ string ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.allowedMoney [ Money ]
        # EligibilityResponse.insurance.benefitBalance.financial.used[x] : 0..1 Benefits used. One of these 2
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedUnsignedInt [ unsignedInt ]
          fhir:EligibilityResponse.insurance.benefitBalance.financial.usedMoney [ Money ]
      ], ...;
    ], ...;
  ], ...;
  fhir:EligibilityResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference
  fhir:EligibilityResponse.authorization [ # 0..* Services which may require prior authorization
    fhir:EligibilityResponse.authorization.authorizationSequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:EligibilityResponse.authorization.required [ boolean ]; # 1..1 Authorization required flag
    fhir:EligibilityResponse.authorization.note [ Annotation ], ... ; # 0..* Comments and instructions
  ], ...;

  fhir:EligibilityResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:EligibilityResponse.error [ # 0..* Processing errors
    fhir:EligibilityResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since DSTU2

EligibilityResponse.status
EligibilityResponse Added Element
EligibilityResponse.outcome EligibilityResponse.requestProvider
  • Type changed from code Reference(Practitioner) to CodeableConcept EligibilityResponse.insurer Added Element EligibilityResponse.inforce Added Element EligibilityResponse.insurance Added Element EligibilityResponse.insurance.coverage Added Element EligibilityResponse.insurance.contract Added Element EligibilityResponse.insurance.benefitBalance Added Element EligibilityResponse.insurance.benefitBalance.category Added Element EligibilityResponse.insurance.benefitBalance.subCategory Added Element EligibilityResponse.insurance.benefitBalance.excluded Added Element EligibilityResponse.insurance.benefitBalance.name Added Element EligibilityResponse.insurance.benefitBalance.description Added Element EligibilityResponse.insurance.benefitBalance.network Added Element EligibilityResponse.insurance.benefitBalance.unit Added Element EligibilityResponse.insurance.benefitBalance.term Added Element EligibilityResponse.insurance.benefitBalance.financial Added Element Reference(Practitioner|PractitionerRole|Organization)
EligibilityResponse.insurance.benefitBalance.financial.type EligibilityResponse.outcome
  • Added Element Type changed from CodeableConcept to code
EligibilityResponse.insurance.benefitBalance.financial.allowed[x] EligibilityResponse.preAuthRef
  • Added Element
EligibilityResponse.insurance.benefitBalance.financial.used[x] EligibilityResponse.authorization
  • Added Element
EligibilityResponse.form EligibilityResponse.authorization.authorizationSequence
  • Added Element
EligibilityResponse.error EligibilityResponse.authorization.required
  • Added Element
EligibilityResponse.error.code EligibilityResponse.authorization.note
  • Added Element
EligibilityResponse.ruleset deleted EligibilityResponse.originalRuleset deleted EligibilityResponse.organization EligibilityResponse.requestOrganization
  • 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

13.3.2.1 Terminology Bindings

Path Definition Type Reference
EligibilityResponse.status A code specifying the state of the resource instance. Required Financial Resource Status Codes
EligibilityResponse.outcome The outcome of the processing. Required RemittanceOutcome
EligibilityResponse.insurance.benefitBalance.category Benefit categories such as: oral, medical, vision etc. Example Benefit Category Codes
EligibilityResponse.insurance.benefitBalance.subCategory Benefit subcategories such as: oral-basic, major, glasses Example Benefit SubCategory Codes
EligibilityResponse.insurance.benefitBalance.network Code to classify in or out of network services Example Network Type Codes
EligibilityResponse.insurance.benefitBalance.unit Unit covered/serviced - individual or family Example Unit Type Codes
EligibilityResponse.insurance.benefitBalance.term Coverage unit - annual, lifetime Example Benefit Term Codes
EligibilityResponse.insurance.benefitBalance.financial.type Deductable, visits, co-pay, etc. Example Benefit Type Codes
EligibilityResponse.form The forms codes. Example Form Codes
EligibilityResponse.error.code The error codes for adjudication processing. Example Adjudication Error Codes

13.3.3 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 EligibilityResponse.created
disposition string The contents of the disposition message EligibilityResponse.disposition
identifier token The business identifier EligibilityResponse.identifier
insurer reference The organization which generated this resource EligibilityResponse.insurer
( Organization )
outcome token The processing outcome EligibilityResponse.outcome
request reference The EligibilityRequest reference EligibilityResponse.request
( EligibilityRequest )
request-organization request-provider reference The EligibilityRequest organization provider EligibilityResponse.requestOrganization EligibilityResponse.requestProvider
( Practitioner , Organization , PractitionerRole )
request-provider status reference token The EligibilityRequest provider status EligibilityResponse.requestProvider ( Practitioner ) EligibilityResponse.status