FHIR Implementation Guide for ABDM
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FHIR Implementation Guide for ABDM - Local Development build (v7.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: CoverageEligibilityRequest

Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/CoverageEligibilityRequest Version: 7.0.0
Draft as of 2025-03-18 Computable Name: 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.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityRequest 0..* CoverageEligibilityRequest CoverageEligibilityRequest resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..1 Identifier Business Identifier for coverage eligiblity request
... 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
... 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
.... 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
... insurance S 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage S 1..1 Reference(Coverage) Insurance information
... item S 0..* BackboneElement Item to be evaluated for eligibiity
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category (example)
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
.... provider 0..1 Reference(Practitioner | PractitionerRole) Perfoming practitioner
.... facility 0..1 Reference(Location | Organization) Servicing facility
.... diagnosis S 0..* BackboneElement Applicable diagnosis
..... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityRequest.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​purpose Base required EligibilityRequestPurpose 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityRequest.​item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityRequest.​item.diagnosis.diagnosis[x] Base example ICD10 Diagnostic codes 📦7.0.0 This IG

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
CoverageEligibilityRequest.​item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityRequest.​item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityRequest.​item.diagnosis.diagnosis[x] Base example ICD10 Diagnostic codes 📦7.0.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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(4.0.1) 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityRequest.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​purpose Base required EligibilityRequestPurpose 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityRequest.​item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityRequest.​item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​item.diagnosis.diagnosis[x] Base example ICD10 Diagnostic codes 📦7.0.0 This IG

Constraints

Id Grade Path(s) Description Expression
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityRequest 0..* CoverageEligibilityRequest CoverageEligibilityRequest resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..1 Identifier Business Identifier for coverage eligiblity request
... 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
... 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
.... 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
... insurance S 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage S 1..1 Reference(Coverage) Insurance information
... item S 0..* BackboneElement Item to be evaluated for eligibiity
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category (example)
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
.... provider 0..1 Reference(Practitioner | PractitionerRole) Perfoming practitioner
.... facility 0..1 Reference(Location | Organization) Servicing facility
.... diagnosis S 0..* BackboneElement Applicable diagnosis
..... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityRequest.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​purpose Base required EligibilityRequestPurpose 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityRequest.​item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityRequest.​item.diagnosis.diagnosis[x] Base example ICD10 Diagnostic codes 📦7.0.0 This IG

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
CoverageEligibilityRequest.​item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityRequest.​item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityRequest.​item.diagnosis.diagnosis[x] Base example ICD10 Diagnostic codes 📦7.0.0 This IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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(4.0.1) 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityRequest.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​purpose Base required EligibilityRequestPurpose 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityRequest.​item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityRequest.​item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityRequest.​item.diagnosis.diagnosis[x] Base example ICD10 Diagnostic codes 📦7.0.0 This IG

Constraints

Id Grade Path(s) Description Expression
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()

 

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