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: CoverageEligibilityResponse

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

Usage:

• Use this Resource Profile: CoverageEligibilityResponseBundle
• Examples for this Resource Profile: CoverageEligibilityResponse/auth-requirements-example-01, CoverageEligibilityResponse/benefits-example-01, CoverageEligibilityResponse/discovery-example-01 and CoverageEligibilityResponse/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
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse 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
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
purpose	SΣ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (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	Response creation date ele-1: All FHIR elements must have a @value or children
requestor		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request ele-1: All FHIR elements must have a @value or children
request	Σ	1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference ele-1: All FHIR elements must have a @value or children
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing. ele-1: All FHIR elements must have a @value or children
disposition	S	0..1	string	Disposition Message ele-1: All FHIR elements must have a @value or children
insurer	SΣ	1..1	Reference(Organization)	Coverage issuer ele-1: All FHIR elements must have a @value or children
insurance	S	0..*	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	SΣ	1..1	Reference(Coverage)	Insurance information ele-1: All FHIR elements must have a @value or children
inforce	S	0..1	boolean	Coverage inforce indicator ele-1: All FHIR elements must have a @value or children
item	SC	0..*	BackboneElement	Benefits and authorization details ces-1: SHALL contain a category or a billcode but not both. 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): Allowable service and product codes . ele-1: All FHIR elements must have a @value or children
provider		0..1	Reference(Practitioner | PractitionerRole)	Performing practitioner ele-1: All FHIR elements must have a @value or children
benefit	S	0..*	BackboneElement	Benefit Summary 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
type		1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. ele-1: All FHIR elements must have a @value or children
error	S	0..*	BackboneElement	Processing errors 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
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing. ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityResponse.insurance.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard
CoverageEligibilityResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
ces-1	error	CoverageEligibilityResponse.insurance.item	SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists()
dom-2	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityResponse	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	CoverageEligibilityResponse	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	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityResponse	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 CoverageEligibilityResponse

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse resource
purpose	S	1..*	code	auth-requirements | benefits | discovery | validation
patient		1..1	Reference(Patient)	Intended recipient of products and services
requestor		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
request		1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference
outcome	S	1..1	code	queued | complete | error | partial
disposition	S	0..1	string	Disposition Message
insurer	S	1..1	Reference(Organization)	Coverage issuer
insurance	S	0..*	BackboneElement	Patient insurance information
coverage	S	1..1	Reference(Coverage)	Insurance information
inforce	S	0..1	boolean	Coverage inforce indicator
item	S	0..*	BackboneElement	Benefits and authorization details
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): Allowable service and product codes .
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)	Performing practitioner
benefit	S	0..*	BackboneElement	Benefit Summary
error	S	0..*	BackboneElement	Processing errors
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityResponse.insurance.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse 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		0..*	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.
purpose	SΣ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (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	Response creation date
requestor		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
request	Σ	1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing.
disposition	S	0..1	string	Disposition Message
insurer	SΣ	1..1	Reference(Organization)	Coverage issuer
insurance	S	0..*	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
coverage	SΣ	1..1	Reference(Coverage)	Insurance information
inforce	S	0..1	boolean	Coverage inforce indicator
benefitPeriod		0..1	Period	When the benefits are applicable
item	SC	0..*	BackboneElement	Benefits and authorization details ces-1: SHALL contain a category or a billcode but not both.
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
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): Allowable service and product codes .
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)	Performing practitioner
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 Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
benefit	S	0..*	BackboneElement	Benefit Summary
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
type		1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x]		0..1		Benefits allowed
allowedUnsignedInt			unsignedInt
allowedString			string
allowedMoney			Money
used[x]		0..1		Benefits used
usedUnsignedInt			unsignedInt
usedString			string
usedMoney			Money
authorizationRequired		0..1	boolean	Authorization required flag
authorizationSupporting		0..*	CodeableConcept	Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
authorizationUrl		0..1	uri	Preauthorization requirements endpoint
preAuthRef		0..1	string	Preauthorization reference
form		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
error	S	0..*	BackboneElement	Processing errors
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
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityResponse.insurance.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityResponse.insurance.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
CoverageEligibilityResponse.insurance.item.network	example	NetworkTypeCodes http://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard
CoverageEligibilityResponse.insurance.item.unit	example	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard
CoverageEligibilityResponse.insurance.item.term	example	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support from the FHIR Standard
CoverageEligibilityResponse.form	example	Form Codes http://hl7.org/fhir/ValueSet/forms from the FHIR Standard
CoverageEligibilityResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
ces-1	error	CoverageEligibilityResponse.insurance.item	SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists()
dom-2	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityResponse	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	CoverageEligibilityResponse	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	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityResponse	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 CoverageEligibilityResponse

Summary

Mandatory: 1 element(7 nested mandatory elements)
Must-Support: 11 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)
• CoverageEligibilityRequest (https://nrces.in/ndhm/fhir/r4/StructureDefinition/CoverageEligibilityRequest)
• Coverage (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Coverage)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse 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
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
purpose	SΣ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (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	Response creation date ele-1: All FHIR elements must have a @value or children
requestor		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request ele-1: All FHIR elements must have a @value or children
request	Σ	1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference ele-1: All FHIR elements must have a @value or children
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing. ele-1: All FHIR elements must have a @value or children
disposition	S	0..1	string	Disposition Message ele-1: All FHIR elements must have a @value or children
insurer	SΣ	1..1	Reference(Organization)	Coverage issuer ele-1: All FHIR elements must have a @value or children
insurance	S	0..*	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	SΣ	1..1	Reference(Coverage)	Insurance information ele-1: All FHIR elements must have a @value or children
inforce	S	0..1	boolean	Coverage inforce indicator ele-1: All FHIR elements must have a @value or children
item	SC	0..*	BackboneElement	Benefits and authorization details ces-1: SHALL contain a category or a billcode but not both. 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): Allowable service and product codes . ele-1: All FHIR elements must have a @value or children
provider		0..1	Reference(Practitioner | PractitionerRole)	Performing practitioner ele-1: All FHIR elements must have a @value or children
benefit	S	0..*	BackboneElement	Benefit Summary 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
type		1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. ele-1: All FHIR elements must have a @value or children
error	S	0..*	BackboneElement	Processing errors 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
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing. ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityResponse.insurance.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard
CoverageEligibilityResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
ces-1	error	CoverageEligibilityResponse.insurance.item	SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists()
dom-2	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityResponse	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	CoverageEligibilityResponse	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	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityResponse	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 CoverageEligibilityResponse

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse resource
purpose	S	1..*	code	auth-requirements | benefits | discovery | validation
patient		1..1	Reference(Patient)	Intended recipient of products and services
requestor		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
request		1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference
outcome	S	1..1	code	queued | complete | error | partial
disposition	S	0..1	string	Disposition Message
insurer	S	1..1	Reference(Organization)	Coverage issuer
insurance	S	0..*	BackboneElement	Patient insurance information
coverage	S	1..1	Reference(Coverage)	Insurance information
inforce	S	0..1	boolean	Coverage inforce indicator
item	S	0..*	BackboneElement	Benefits and authorization details
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): Allowable service and product codes .
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)	Performing practitioner
benefit	S	0..*	BackboneElement	Benefit Summary
error	S	0..*	BackboneElement	Processing errors
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityResponse.insurance.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse 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		0..*	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.
purpose	SΣ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (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	Response creation date
requestor		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
request	Σ	1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing.
disposition	S	0..1	string	Disposition Message
insurer	SΣ	1..1	Reference(Organization)	Coverage issuer
insurance	S	0..*	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
coverage	SΣ	1..1	Reference(Coverage)	Insurance information
inforce	S	0..1	boolean	Coverage inforce indicator
benefitPeriod		0..1	Period	When the benefits are applicable
item	SC	0..*	BackboneElement	Benefits and authorization details ces-1: SHALL contain a category or a billcode but not both.
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
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): Allowable service and product codes .
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)	Performing practitioner
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 Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
benefit	S	0..*	BackboneElement	Benefit Summary
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
type		1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x]		0..1		Benefits allowed
allowedUnsignedInt			unsignedInt
allowedString			string
allowedMoney			Money
used[x]		0..1		Benefits used
usedUnsignedInt			unsignedInt
usedString			string
usedMoney			Money
authorizationRequired		0..1	boolean	Authorization required flag
authorizationSupporting		0..*	CodeableConcept	Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
authorizationUrl		0..1	uri	Preauthorization requirements endpoint
preAuthRef		0..1	string	Preauthorization reference
form		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
error	S	0..*	BackboneElement	Processing errors
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
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
CoverageEligibilityResponse.insurance.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
CoverageEligibilityResponse.insurance.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
CoverageEligibilityResponse.insurance.item.network	example	NetworkTypeCodes http://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard
CoverageEligibilityResponse.insurance.item.unit	example	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard
CoverageEligibilityResponse.insurance.item.term	example	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support from the FHIR Standard
CoverageEligibilityResponse.form	example	Form Codes http://hl7.org/fhir/ValueSet/forms from the FHIR Standard
CoverageEligibilityResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
ces-1	error	CoverageEligibilityResponse.insurance.item	SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists()
dom-2	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityResponse	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	CoverageEligibilityResponse	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	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityResponse	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 CoverageEligibilityResponse

Summary

Mandatory: 1 element(7 nested mandatory elements)
Must-Support: 11 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)
• CoverageEligibilityRequest (https://nrces.in/ndhm/fhir/r4/StructureDefinition/CoverageEligibilityRequest)
• Coverage (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Coverage)

Other representations of profile: CSV, Excel, Schematron