FHIR Implementation Guide for ABDM
3.1.0 - active
FHIR Implementation Guide for ABDM
3.1.0 - active
FHIR Implementation Guide for ABDM - Local Development build (v3.1.0). See the Directory of published versions
| Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/CoverageEligibilityRequest | Version: 3.1.0 | |||
| Draft as of 2023-08-10 | 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.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CoverageEligibilityRequest
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |
  identifier | S | 1..1 | Identifier | Business Identifier for coverage eligiblity request |
| priority | 1..1 | CodeableConcept | Desired processing priority | |
| purpose | S | 1..* | code | auth-requirements | benefits | discovery | validation |
 patient | 1..1 | Reference(Patient) | Intended recipient of products and services | |
| created | 1..1 | dateTime | Creation date | |
| enterer | 1..1 | Reference(Practitioner | PractitionerRole) | Author | |
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |
| insurer | 1..1 | Reference(Organization) | Coverage issuer | |
| facility | 1..1 | Reference(Location) | Servicing facility | |
| supportingInfo | S | 0..* | BackboneElement | Supporting information |
 insurance | S | 1..* | BackboneElement | Patient insurance information |
  coverage | S | 1..1 | Reference(Coverage) | Insurance information |
 item | S | 0..* | BackboneElement | Item to be evaluated for eligibiity |
 category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category (example) | |
| 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 |
 diagnosis[x] | 0..1 | Nature of illness or problem | ||
 diagnosisCodeableConcept | CodeableConcept | |||
| diagnosisReference | Reference(Condition) | |||
| detail | 0..* | Reference(Resource) | Product or service details | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| CoverageEligibilityRequest.item.category | example | BenefitCategory |
| CoverageEligibilityRequest.item.productOrService | example | ProductorService |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 |
| 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 |
| 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: ICD-10Codes (example): ICD10 Diagnostic codes. | ||
| diagnosisCodeableConcept | CodeableConcept | |||
| diagnosisReference | Reference(Condition) | |||
| detail | 0..* | Reference(Resource) | Product or service details | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| CoverageEligibilityRequest.status | required | FinancialResourceStatusCodes |
| CoverageEligibilityRequest.priority | example | ProcessPriorityCodes |
| CoverageEligibilityRequest.purpose | required | EligibilityRequestPurpose |
| CoverageEligibilityRequest.item.category | example | BenefitCategory |
| CoverageEligibilityRequest.item.productOrService | example | ProductorService |
| CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | example | ICD-10Codes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | CoverageEligibilityRequest | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | CoverageEligibilityRequest | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | CoverageEligibilityRequest | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | CoverageEligibilityRequest | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | CoverageEligibilityRequest | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | S | 1..1 | Identifier | Business Identifier for coverage eligiblity request | ||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| priority | 1..1 | CodeableConcept | Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred. | |||||
| purpose | SΣ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested. | ||||
| patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services | ||||
| serviced[x] | 0..1 | Estimated date or dates of service | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| created | Σ | 1..1 | dateTime | Creation date | ||||
| enterer | 1..1 | Reference(Practitioner | PractitionerRole) | Author | |||||
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |||||
| insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer | ||||
| facility | 1..1 | Reference(Location) | Servicing facility | |||||
| supportingInfo | S | 0..* | BackboneElement | Supporting information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Information instance identifier | |||||
| information | 1..1 | Reference(Resource) | Data to be provided | |||||
| appliesToAll | 0..1 | boolean | Applies to all items | |||||
| insurance | S | 1..* | BackboneElement | Patient insurance information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| focal | 0..1 | boolean | Applicable coverage | |||||
| coverage | S | 1..1 | Reference(Coverage) | Insurance information | ||||
| businessArrangement | 0..1 | string | Additional provider contract number | |||||
| item | S | 0..* | BackboneElement | Item to be evaluated for eligibiity | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| supportingInfoSequence | 0..* | positiveInt | Applicable exception or supporting information | |||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category (example) | |||||
| productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | ||||
| modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| provider | 0..1 | Reference(Practitioner | PractitionerRole) | Perfoming practitioner | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| facility | 0..1 | Reference(Location | Organization) | Servicing facility | |||||
| diagnosis | S | 0..* | BackboneElement | Applicable diagnosis | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| diagnosis[x] | 0..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
| diagnosisCodeableConcept | CodeableConcept | |||||||
| diagnosisReference | Reference(Condition) | |||||||
| detail | 0..* | Reference(Resource) | Product or service details | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| CoverageEligibilityRequest.language | preferred | CommonLanguages
| ||||
| CoverageEligibilityRequest.status | required | FinancialResourceStatusCodes | ||||
| CoverageEligibilityRequest.priority | example | ProcessPriorityCodes | ||||
| CoverageEligibilityRequest.purpose | required | EligibilityRequestPurpose | ||||
| CoverageEligibilityRequest.item.category | example | BenefitCategory | ||||
| CoverageEligibilityRequest.item.productOrService | example | ProductorService | ||||
| CoverageEligibilityRequest.item.modifier | example | ModifierTypeCodes | ||||
| CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | example | ICD-10Codes |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from CoverageEligibilityRequest
Summary
Mandatory: 6 elements (1 nested mandatory element)
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from CoverageEligibilityRequest
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |
| identifier | S | 1..1 | Identifier | Business Identifier for coverage eligiblity request |
| priority | 1..1 | CodeableConcept | Desired processing priority | |
| purpose | S | 1..* | code | auth-requirements | benefits | discovery | validation |
| patient | 1..1 | Reference(Patient) | Intended recipient of products and services | |
| created | 1..1 | dateTime | Creation date | |
| enterer | 1..1 | Reference(Practitioner | PractitionerRole) | Author | |
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |
| insurer | 1..1 | Reference(Organization) | Coverage issuer | |
| facility | 1..1 | Reference(Location) | Servicing facility | |
| supportingInfo | S | 0..* | BackboneElement | Supporting information |
| insurance | S | 1..* | BackboneElement | Patient insurance information |
| coverage | S | 1..1 | Reference(Coverage) | Insurance information |
| item | S | 0..* | BackboneElement | Item to be evaluated for eligibiity |
| category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category (example) | |
| 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 |
| diagnosis[x] | 0..1 | Nature of illness or problem | ||
| diagnosisCodeableConcept | CodeableConcept | |||
| diagnosisReference | Reference(Condition) | |||
| detail | 0..* | Reference(Resource) | Product or service details | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| CoverageEligibilityRequest.item.category | example | BenefitCategory |
| CoverageEligibilityRequest.item.productOrService | example | ProductorService |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 |
| 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 |
| 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: ICD-10Codes (example): ICD10 Diagnostic codes. | ||
| diagnosisCodeableConcept | CodeableConcept | |||
| diagnosisReference | Reference(Condition) | |||
| detail | 0..* | Reference(Resource) | Product or service details | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| CoverageEligibilityRequest.status | required | FinancialResourceStatusCodes |
| CoverageEligibilityRequest.priority | example | ProcessPriorityCodes |
| CoverageEligibilityRequest.purpose | required | EligibilityRequestPurpose |
| CoverageEligibilityRequest.item.category | example | BenefitCategory |
| CoverageEligibilityRequest.item.productOrService | example | ProductorService |
| CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | example | ICD-10Codes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | CoverageEligibilityRequest | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | CoverageEligibilityRequest | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | CoverageEligibilityRequest | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | CoverageEligibilityRequest | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | CoverageEligibilityRequest | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | S | 1..1 | Identifier | Business Identifier for coverage eligiblity request | ||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| priority | 1..1 | CodeableConcept | Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred. | |||||
| purpose | SΣ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested. | ||||
| patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services | ||||
| serviced[x] | 0..1 | Estimated date or dates of service | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| created | Σ | 1..1 | dateTime | Creation date | ||||
| enterer | 1..1 | Reference(Practitioner | PractitionerRole) | Author | |||||
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |||||
| insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer | ||||
| facility | 1..1 | Reference(Location) | Servicing facility | |||||
| supportingInfo | S | 0..* | BackboneElement | Supporting information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Information instance identifier | |||||
| information | 1..1 | Reference(Resource) | Data to be provided | |||||
| appliesToAll | 0..1 | boolean | Applies to all items | |||||
| insurance | S | 1..* | BackboneElement | Patient insurance information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| focal | 0..1 | boolean | Applicable coverage | |||||
| coverage | S | 1..1 | Reference(Coverage) | Insurance information | ||||
| businessArrangement | 0..1 | string | Additional provider contract number | |||||
| item | S | 0..* | BackboneElement | Item to be evaluated for eligibiity | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| supportingInfoSequence | 0..* | positiveInt | Applicable exception or supporting information | |||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category (example) | |||||
| productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | ||||
| modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| provider | 0..1 | Reference(Practitioner | PractitionerRole) | Perfoming practitioner | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| facility | 0..1 | Reference(Location | Organization) | Servicing facility | |||||
| diagnosis | S | 0..* | BackboneElement | Applicable diagnosis | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| diagnosis[x] | 0..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
| diagnosisCodeableConcept | CodeableConcept | |||||||
| diagnosisReference | Reference(Condition) | |||||||
| detail | 0..* | Reference(Resource) | Product or service details | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| CoverageEligibilityRequest.language | preferred | CommonLanguages
| ||||
| CoverageEligibilityRequest.status | required | FinancialResourceStatusCodes | ||||
| CoverageEligibilityRequest.priority | example | ProcessPriorityCodes | ||||
| CoverageEligibilityRequest.purpose | required | EligibilityRequestPurpose | ||||
| CoverageEligibilityRequest.item.category | example | BenefitCategory | ||||
| CoverageEligibilityRequest.item.productOrService | example | ProductorService | ||||
| CoverageEligibilityRequest.item.modifier | example | ModifierTypeCodes | ||||
| CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | example | ICD-10Codes |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from CoverageEligibilityRequest
Summary
Mandatory: 6 elements (1 nested mandatory element)
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron