FHIR Implementation Guide for ABDM
4.0.0 - active
FHIR Implementation Guide for ABDM
4.0.0 - active
FHIR Implementation Guide for ABDM - Local Development build (v4.0.0). See the Directory of published versions
| Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/CoverageEligibilityResponse | Version: 4.0.0 | |||
| Draft as of 2023-11-06 | Computable Name: CoverageEligibilityResponse | |||
This profile provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CoverageEligibilityResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  CoverageEligibilityResponse | 0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |
  purpose | S | 1..* | code | auth-requirements | benefits | discovery | validation |
 patient | 1..1 | Reference(Patient) | Intended recipient of products and services | |
| requestor | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |
| request | 1..1 | Reference(CoverageEligibilityRequest) | Eligibility request reference | |
| outcome | S | 1..1 | code | queued | complete | error | partial |
| disposition | S | 0..1 | string | Disposition Message |
| insurer | S | 1..1 | Reference(Organization) | Coverage issuer |
 insurance | S | 0..* | BackboneElement | Patient insurance information |
 coverage | S | 1..1 | Reference(Coverage) | Insurance information |
| inforce | S | 0..1 | boolean | Coverage inforce indicator |
 item | S | 0..* | BackboneElement | Benefits and authorization details |
 category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
 display | 1..1 | string | Representation defined by the system | |
| productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example): Allowable service and product codes . |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| provider | 0..1 | Reference(Practitioner | PractitionerRole) | Performing practitioner | |
| benefit | S | 0..* | BackboneElement | Benefit Summary |
| error | S | 0..* | BackboneElement | Processing errors |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| CoverageEligibilityResponse.insurance.item.category | example | BenefitCategory |
| CoverageEligibilityResponse.insurance.item.productOrService | example | ProductorService |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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. |
| 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 |
| 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 |
| 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. | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| CoverageEligibilityResponse.status | required | FinancialResourceStatusCodes |
| CoverageEligibilityResponse.purpose | required | EligibilityResponsePurpose |
| CoverageEligibilityResponse.outcome | required | ClaimProcessingCodes |
| CoverageEligibilityResponse.insurance.item.category | example | BenefitCategory |
| CoverageEligibilityResponse.insurance.item.productOrService | example | ProductorService |
| CoverageEligibilityResponse.insurance.item.benefit.type | example | BenefitTypeCodes |
| CoverageEligibilityResponse.error.code | example | Adjudication Error Codes |
| Id | Grade | Path(s) | Details | Requirements |
| ces-1 | error | CoverageEligibilityResponse.insurance.item | SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists() | |
| dom-2 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | CoverageEligibilityResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| CoverageEligibilityResponse | 0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | 0..* | Identifier | Business Identifier for coverage eligiblity request | |||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| purpose | SΣ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested. | ||||
| patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services | ||||
 serviced[x] | 0..1 | Estimated date or dates of service | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| created | Σ | 1..1 | dateTime | Response creation date | ||||
| requestor | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |||||
| request | Σ | 1..1 | Reference(CoverageEligibilityRequest) | Eligibility request reference | ||||
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing. | ||||
| disposition | S | 0..1 | string | Disposition Message | ||||
| insurer | SΣ | 1..1 | Reference(Organization) | Coverage issuer | ||||
| insurance | S | 0..* | BackboneElement | Patient insurance information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| coverage | SΣ | 1..1 | Reference(Coverage) | Insurance information | ||||
| inforce | S | 0..1 | boolean | Coverage inforce indicator | ||||
| benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
| item | SC | 0..* | BackboneElement | Benefits and authorization details | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example): Allowable service and product codes . | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| provider | 0..1 | Reference(Practitioner | PractitionerRole) | Performing practitioner | |||||
| excluded | 0..1 | boolean | Excluded from the plan | |||||
| name | 0..1 | string | Short name for the benefit | |||||
| description | 0..1 | string | Description of the benefit or services covered | |||||
| network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
| unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
| term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
| benefit | S | 0..* | BackboneElement | Benefit Summary | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
| allowed[x] | 0..1 | Benefits allowed | ||||||
| allowedUnsignedInt | unsignedInt | |||||||
| allowedString | string | |||||||
| allowedMoney | Money | |||||||
| used[x] | 0..1 | Benefits used | ||||||
| usedUnsignedInt | unsignedInt | |||||||
| usedString | string | |||||||
| usedMoney | Money | |||||||
| authorizationRequired | 0..1 | boolean | Authorization required flag | |||||
| authorizationSupporting | 0..* | CodeableConcept | Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization. | |||||
| authorizationUrl | 0..1 | uri | Preauthorization requirements endpoint | |||||
| preAuthRef | 0..1 | string | Preauthorization reference | |||||
| form | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| error | S | 0..* | BackboneElement | Processing errors | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| CoverageEligibilityResponse.language | preferred | CommonLanguages
| ||||
| CoverageEligibilityResponse.status | required | FinancialResourceStatusCodes | ||||
| CoverageEligibilityResponse.purpose | required | EligibilityResponsePurpose | ||||
| CoverageEligibilityResponse.outcome | required | ClaimProcessingCodes | ||||
| CoverageEligibilityResponse.insurance.item.category | example | BenefitCategory | ||||
| CoverageEligibilityResponse.insurance.item.productOrService | example | ProductorService | ||||
| CoverageEligibilityResponse.insurance.item.modifier | example | ModifierTypeCodes | ||||
| CoverageEligibilityResponse.insurance.item.network | example | NetworkTypeCodes | ||||
| CoverageEligibilityResponse.insurance.item.unit | example | UnitTypeCodes | ||||
| CoverageEligibilityResponse.insurance.item.term | example | BenefitTermCodes | ||||
| CoverageEligibilityResponse.insurance.item.benefit.type | example | BenefitTypeCodes | ||||
| CoverageEligibilityResponse.insurance.item.authorizationSupporting | example | CoverageEligibilityResponseAuthSupportCodes | ||||
| CoverageEligibilityResponse.form | example | Form Codes | ||||
| CoverageEligibilityResponse.error.code | example | Adjudication Error Codes |
| Id | Grade | Path(s) | Details | Requirements |
| ces-1 | error | CoverageEligibilityResponse.insurance.item | SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists() | |
| dom-2 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | CoverageEligibilityResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from CoverageEligibilityResponse
Summary
Mandatory: 1 element (7 nested mandatory elements)
Must-Support: 11 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from CoverageEligibilityResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| CoverageEligibilityResponse | 0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |
| purpose | S | 1..* | code | auth-requirements | benefits | discovery | validation |
| patient | 1..1 | Reference(Patient) | Intended recipient of products and services | |
| requestor | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |
| request | 1..1 | Reference(CoverageEligibilityRequest) | Eligibility request reference | |
| outcome | S | 1..1 | code | queued | complete | error | partial |
| disposition | S | 0..1 | string | Disposition Message |
| insurer | S | 1..1 | Reference(Organization) | Coverage issuer |
| insurance | S | 0..* | BackboneElement | Patient insurance information |
| coverage | S | 1..1 | Reference(Coverage) | Insurance information |
| inforce | S | 0..1 | boolean | Coverage inforce indicator |
| item | S | 0..* | BackboneElement | Benefits and authorization details |
| category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example): Allowable service and product codes . |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| provider | 0..1 | Reference(Practitioner | PractitionerRole) | Performing practitioner | |
| benefit | S | 0..* | BackboneElement | Benefit Summary |
| error | S | 0..* | BackboneElement | Processing errors |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| CoverageEligibilityResponse.insurance.item.category | example | BenefitCategory |
| CoverageEligibilityResponse.insurance.item.productOrService | example | ProductorService |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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. |
| 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 |
| 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 |
| 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. | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| CoverageEligibilityResponse.status | required | FinancialResourceStatusCodes |
| CoverageEligibilityResponse.purpose | required | EligibilityResponsePurpose |
| CoverageEligibilityResponse.outcome | required | ClaimProcessingCodes |
| CoverageEligibilityResponse.insurance.item.category | example | BenefitCategory |
| CoverageEligibilityResponse.insurance.item.productOrService | example | ProductorService |
| CoverageEligibilityResponse.insurance.item.benefit.type | example | BenefitTypeCodes |
| CoverageEligibilityResponse.error.code | example | Adjudication Error Codes |
| Id | Grade | Path(s) | Details | Requirements |
| ces-1 | error | CoverageEligibilityResponse.insurance.item | SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists() | |
| dom-2 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | CoverageEligibilityResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| CoverageEligibilityResponse | 0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | 0..* | Identifier | Business Identifier for coverage eligiblity request | |||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| purpose | SΣ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested. | ||||
| patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services | ||||
| serviced[x] | 0..1 | Estimated date or dates of service | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| created | Σ | 1..1 | dateTime | Response creation date | ||||
| requestor | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |||||
| request | Σ | 1..1 | Reference(CoverageEligibilityRequest) | Eligibility request reference | ||||
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing. | ||||
| disposition | S | 0..1 | string | Disposition Message | ||||
| insurer | SΣ | 1..1 | Reference(Organization) | Coverage issuer | ||||
| insurance | S | 0..* | BackboneElement | Patient insurance information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| coverage | SΣ | 1..1 | Reference(Coverage) | Insurance information | ||||
| inforce | S | 0..1 | boolean | Coverage inforce indicator | ||||
| benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
| item | SC | 0..* | BackboneElement | Benefits and authorization details | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example): Allowable service and product codes . | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| provider | 0..1 | Reference(Practitioner | PractitionerRole) | Performing practitioner | |||||
| excluded | 0..1 | boolean | Excluded from the plan | |||||
| name | 0..1 | string | Short name for the benefit | |||||
| description | 0..1 | string | Description of the benefit or services covered | |||||
| network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
| unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
| term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
| benefit | S | 0..* | BackboneElement | Benefit Summary | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
| allowed[x] | 0..1 | Benefits allowed | ||||||
| allowedUnsignedInt | unsignedInt | |||||||
| allowedString | string | |||||||
| allowedMoney | Money | |||||||
| used[x] | 0..1 | Benefits used | ||||||
| usedUnsignedInt | unsignedInt | |||||||
| usedString | string | |||||||
| usedMoney | Money | |||||||
| authorizationRequired | 0..1 | boolean | Authorization required flag | |||||
| authorizationSupporting | 0..* | CodeableConcept | Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization. | |||||
| authorizationUrl | 0..1 | uri | Preauthorization requirements endpoint | |||||
| preAuthRef | 0..1 | string | Preauthorization reference | |||||
| form | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| error | S | 0..* | BackboneElement | Processing errors | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| CoverageEligibilityResponse.language | preferred | CommonLanguages
| ||||
| CoverageEligibilityResponse.status | required | FinancialResourceStatusCodes | ||||
| CoverageEligibilityResponse.purpose | required | EligibilityResponsePurpose | ||||
| CoverageEligibilityResponse.outcome | required | ClaimProcessingCodes | ||||
| CoverageEligibilityResponse.insurance.item.category | example | BenefitCategory | ||||
| CoverageEligibilityResponse.insurance.item.productOrService | example | ProductorService | ||||
| CoverageEligibilityResponse.insurance.item.modifier | example | ModifierTypeCodes | ||||
| CoverageEligibilityResponse.insurance.item.network | example | NetworkTypeCodes | ||||
| CoverageEligibilityResponse.insurance.item.unit | example | UnitTypeCodes | ||||
| CoverageEligibilityResponse.insurance.item.term | example | BenefitTermCodes | ||||
| CoverageEligibilityResponse.insurance.item.benefit.type | example | BenefitTypeCodes | ||||
| CoverageEligibilityResponse.insurance.item.authorizationSupporting | example | CoverageEligibilityResponseAuthSupportCodes | ||||
| CoverageEligibilityResponse.form | example | Form Codes | ||||
| CoverageEligibilityResponse.error.code | example | Adjudication Error Codes |
| Id | Grade | Path(s) | Details | Requirements |
| ces-1 | error | CoverageEligibilityResponse.insurance.item | SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists() | |
| dom-2 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | CoverageEligibilityResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | CoverageEligibilityResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | CoverageEligibilityResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from CoverageEligibilityResponse
Summary
Mandatory: 1 element (7 nested mandatory elements)
Must-Support: 11 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron