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: CoverageEligibilityResponse

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

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

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
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... 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
.... 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
.... item SC 0..* BackboneElement Benefits and authorization details
Constraints: ces-1
..... 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): Allowable service and product codes .
..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... benefit S 0..* BackboneElement Benefit Summary
...... 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.
... error S 0..* BackboneElement Processing errors
.... 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​error.code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.productOrService Base example ProductorService 📦7.0.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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 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
Constraints: ces-1
..... 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.network Base example Network Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.authorizationSupporting Base example CoverageEligibilityResponse Auth Support Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​form Base example Forms 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​error.code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... patient Σ 1..1 Reference(Patient) Intended recipient of products and services
... 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
.... 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
.... item SC 0..* BackboneElement Benefits and authorization details
Constraints: ces-1
..... 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): Allowable service and product codes .
..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... benefit S 0..* BackboneElement Benefit Summary
...... 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.
... error S 0..* BackboneElement Processing errors
.... 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​error.code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.productOrService Base example ProductorService 📦7.0.0 This IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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 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
Constraints: ces-1
..... 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.productOrService Base example ProductorService 📦7.0.0 This IG
CoverageEligibilityResponse.​insurance.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.network Base example Network Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.authorizationSupporting Base example CoverageEligibilityResponse Auth Support Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​form Base example Forms 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​error.code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

 

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