This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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Resource Profile: CoverageEligibilityRequest

This profile sets minimum expectations for CoverageEligibilityRequest to provide 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.

Usage:

• Use this Resource Profile: CoverageEligibilityRequestBundle
• Refer to this Resource Profile: CoverageEligibilityResponse
• Examples for this Resource Profile: CoverageEligibilityRequest/auth-requirement-example-01, CoverageEligibilityRequest/benefits-example-01, CoverageEligibilityRequest/discovery-example-01 and CoverageEligibilityRequest/validation-example-01

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	S	1..1	Identifier	Business Identifier for coverage eligiblity request ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
priority		1..1	CodeableConcept	Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred. ele-1: All FHIR elements must have a @value or children
purpose	SΣ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested. ele-1: All FHIR elements must have a @value or children
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services ele-1: All FHIR elements must have a @value or children
created	Σ	1..1	dateTime	Creation date ele-1: All FHIR elements must have a @value or children
enterer		1..1	Reference(Practitioner | PractitionerRole)	Author ele-1: All FHIR elements must have a @value or children
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request ele-1: All FHIR elements must have a @value or children
insurer	Σ	1..1	Reference(Organization)	Coverage issuer ele-1: All FHIR elements must have a @value or children
facility		1..1	Reference(Location)	Servicing facility ele-1: All FHIR elements must have a @value or children
supportingInfo	S	0..*	BackboneElement	Supporting information ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
sequence		1..1	positiveInt	Information instance identifier ele-1: All FHIR elements must have a @value or children
information		1..1	Reference(Resource)	Data to be provided ele-1: All FHIR elements must have a @value or children
insurance	S	1..*	BackboneElement	Patient insurance information ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
coverage	S	1..1	Reference(Coverage)	Insurance information ele-1: All FHIR elements must have a @value or children
item	S	0..*	BackboneElement	Item to be evaluated for eligibiity ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example) ele-1: All FHIR elements must have a @value or children
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example) ele-1: All FHIR elements must have a @value or children
provider		0..1	Reference(Practitioner | PractitionerRole)	Perfoming practitioner ele-1: All FHIR elements must have a @value or children
facility		0..1	Reference(Location | Organization)	Servicing facility ele-1: All FHIR elements must have a @value or children
diagnosis	S	0..*	BackboneElement	Applicable diagnosis ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
diagnosis[x]		0..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example) ele-1: All FHIR elements must have a @value or children
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
detail		0..*	Reference(Resource)	Product or service details ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
CoverageEligibilityRequest.purpose	required	EligibilityRequestPurpose http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityRequest.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	CoverageEligibilityRequest	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityRequest	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CoverageEligibilityRequest	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CoverageEligibilityRequest	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityRequest	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from CoverageEligibilityRequest

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource
identifier	S	1..1	Identifier	Business Identifier for coverage eligiblity request
priority		1..1	CodeableConcept	Desired processing priority
purpose	S	1..*	code	auth-requirements | benefits | discovery | validation
patient		1..1	Reference(Patient)	Intended recipient of products and services
created		1..1	dateTime	Creation date
enterer		1..1	Reference(Practitioner | PractitionerRole)	Author
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
insurer		1..1	Reference(Organization)	Coverage issuer
facility		1..1	Reference(Location)	Servicing facility
supportingInfo	S	0..*	BackboneElement	Supporting information
insurance	S	1..*	BackboneElement	Patient insurance information
coverage	S	1..1	Reference(Coverage)	Insurance information
item	S	0..*	BackboneElement	Item to be evaluated for eligibiity
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
provider		0..1	Reference(Practitioner | PractitionerRole)	Perfoming practitioner
facility		0..1	Reference(Location | Organization)	Servicing facility
diagnosis	S	0..*	BackboneElement	Applicable diagnosis
diagnosis[x]		0..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example)
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
detail		0..*	Reference(Resource)	Product or service details
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityRequest.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..1	Identifier	Business Identifier for coverage eligiblity request
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
priority		1..1	CodeableConcept	Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred.
purpose	SΣ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
serviced[x]		0..1		Estimated date or dates of service
servicedDate			date
servicedPeriod			Period
created	Σ	1..1	dateTime	Creation date
enterer		1..1	Reference(Practitioner | PractitionerRole)	Author
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
facility		1..1	Reference(Location)	Servicing facility
supportingInfo	S	0..*	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
information		1..1	Reference(Resource)	Data to be provided
appliesToAll		0..1	boolean	Applies to all items
insurance	S	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal		0..1	boolean	Applicable coverage
coverage	S	1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
item	S	0..*	BackboneElement	Item to be evaluated for eligibiity
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
supportingInfoSequence		0..*	positiveInt	Applicable exception or supporting information
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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	S	0..*	BackboneElement	Applicable diagnosis
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
diagnosis[x]		0..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example)
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
detail		0..*	Reference(Resource)	Product or service details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
CoverageEligibilityRequest.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
CoverageEligibilityRequest.purpose	required	EligibilityRequestPurpose http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityRequest.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityRequest.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	CoverageEligibilityRequest	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityRequest	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CoverageEligibilityRequest	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CoverageEligibilityRequest	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityRequest	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from CoverageEligibilityRequest

Summary

Mandatory: 6 elements(7 nested mandatory elements)
Must-Support: 8 elements

Structures

This structure refers to these other structures:

• Patient (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient)
• Practitioner (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner)
• PractitionerRole (https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole)
• Organization (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization)
• Coverage (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Coverage)
• Condition (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	S	1..1	Identifier	Business Identifier for coverage eligiblity request ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
priority		1..1	CodeableConcept	Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred. ele-1: All FHIR elements must have a @value or children
purpose	SΣ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested. ele-1: All FHIR elements must have a @value or children
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services ele-1: All FHIR elements must have a @value or children
created	Σ	1..1	dateTime	Creation date ele-1: All FHIR elements must have a @value or children
enterer		1..1	Reference(Practitioner | PractitionerRole)	Author ele-1: All FHIR elements must have a @value or children
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request ele-1: All FHIR elements must have a @value or children
insurer	Σ	1..1	Reference(Organization)	Coverage issuer ele-1: All FHIR elements must have a @value or children
facility		1..1	Reference(Location)	Servicing facility ele-1: All FHIR elements must have a @value or children
supportingInfo	S	0..*	BackboneElement	Supporting information ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
sequence		1..1	positiveInt	Information instance identifier ele-1: All FHIR elements must have a @value or children
information		1..1	Reference(Resource)	Data to be provided ele-1: All FHIR elements must have a @value or children
insurance	S	1..*	BackboneElement	Patient insurance information ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
coverage	S	1..1	Reference(Coverage)	Insurance information ele-1: All FHIR elements must have a @value or children
item	S	0..*	BackboneElement	Item to be evaluated for eligibiity ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example) ele-1: All FHIR elements must have a @value or children
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example) ele-1: All FHIR elements must have a @value or children
provider		0..1	Reference(Practitioner | PractitionerRole)	Perfoming practitioner ele-1: All FHIR elements must have a @value or children
facility		0..1	Reference(Location | Organization)	Servicing facility ele-1: All FHIR elements must have a @value or children
diagnosis	S	0..*	BackboneElement	Applicable diagnosis ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
diagnosis[x]		0..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example) ele-1: All FHIR elements must have a @value or children
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
detail		0..*	Reference(Resource)	Product or service details ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
CoverageEligibilityRequest.purpose	required	EligibilityRequestPurpose http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityRequest.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	CoverageEligibilityRequest	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityRequest	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CoverageEligibilityRequest	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CoverageEligibilityRequest	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityRequest	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from CoverageEligibilityRequest

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource
identifier	S	1..1	Identifier	Business Identifier for coverage eligiblity request
priority		1..1	CodeableConcept	Desired processing priority
purpose	S	1..*	code	auth-requirements | benefits | discovery | validation
patient		1..1	Reference(Patient)	Intended recipient of products and services
created		1..1	dateTime	Creation date
enterer		1..1	Reference(Practitioner | PractitionerRole)	Author
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
insurer		1..1	Reference(Organization)	Coverage issuer
facility		1..1	Reference(Location)	Servicing facility
supportingInfo	S	0..*	BackboneElement	Supporting information
insurance	S	1..*	BackboneElement	Patient insurance information
coverage	S	1..1	Reference(Coverage)	Insurance information
item	S	0..*	BackboneElement	Item to be evaluated for eligibiity
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
provider		0..1	Reference(Practitioner | PractitionerRole)	Perfoming practitioner
facility		0..1	Reference(Location | Organization)	Servicing facility
diagnosis	S	0..*	BackboneElement	Applicable diagnosis
diagnosis[x]		0..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example)
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
detail		0..*	Reference(Resource)	Product or service details
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityRequest.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..1	Identifier	Business Identifier for coverage eligiblity request
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
priority		1..1	CodeableConcept	Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred.
purpose	SΣ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
serviced[x]		0..1		Estimated date or dates of service
servicedDate			date
servicedPeriod			Period
created	Σ	1..1	dateTime	Creation date
enterer		1..1	Reference(Practitioner | PractitionerRole)	Author
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
facility		1..1	Reference(Location)	Servicing facility
supportingInfo	S	0..*	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
information		1..1	Reference(Resource)	Data to be provided
appliesToAll		0..1	boolean	Applies to all items
insurance	S	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal		0..1	boolean	Applicable coverage
coverage	S	1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
item	S	0..*	BackboneElement	Item to be evaluated for eligibiity
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
supportingInfoSequence		0..*	positiveInt	Applicable exception or supporting information
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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	S	0..*	BackboneElement	Applicable diagnosis
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
diagnosis[x]		0..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example)
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
detail		0..*	Reference(Resource)	Product or service details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
CoverageEligibilityRequest.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
CoverageEligibilityRequest.purpose	required	EligibilityRequestPurpose http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityRequest.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityRequest.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	CoverageEligibilityRequest	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityRequest	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CoverageEligibilityRequest	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CoverageEligibilityRequest	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityRequest	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from CoverageEligibilityRequest

Summary

Mandatory: 6 elements(7 nested mandatory elements)
Must-Support: 8 elements

Structures

This structure refers to these other structures:

• Patient (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient)
• Practitioner (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner)
• PractitionerRole (https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole)
• Organization (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization)
• Coverage (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Coverage)
• Condition (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition)

Other representations of profile: CSV, Excel, Schematron