FHIR Implementation Guide for HCX
0.7.1 - CI Build

FHIR Implementation Guide for HCX - Local Development build (v0.7.1). See the Directory of published versions

Resource Profile: HCX Coverage Eligibility Request

Defining URL:https://ig.hcxprotocol.io/v0.7.1/StructureDefinition-CoverageEligibilityRequest.html
Version:0.7.1
Name:CoverageEligibilityRequest
Status:Draft as of 2019-11-01 09:29:23+1100 (Standards Status: Trial Use)
Definition:

The CoverageEligibilityRequest provides 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.

Publisher:HCX Open Community
Maturity:1
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

https://ig.hcxprotocol.io/v0.7.1/StructureDefinition-CoverageEligibilityRequest.html

Formal Views of Profile Content

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

This structure is derived from CoverageEligibilityRequest

NameFlagsCard.TypeDescription & Constraintsdoco
​.. CoverageEligibilityRequest 0..*CoverageEligibilityRequestCoverageEligibilityRequest resource
​... identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
​... priority 1..1CodeableConceptDesired processing priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred.

​... patient Σ1..1Reference(Patient)Intended recipient of products and services
​... provider 1..1Reference(Practitioner | Organization)Party responsible for the request
​... insurer Σ1..1Reference(Organization)Coverage issuer
​... insurance
​.... coverage 1..1Reference(Coverage)Insurance information
​... item
​.... category 0..1CodeableConceptBenefit classification
Binding: ClaimServiceCategories (example): Benefit categories such as: oral, medical, vision etc.

​.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: ClaimServiceCodes (example): Allowable service and product codes.

​.... provider 0..1Reference(Practitioner | PractitionerRole)Perfoming practitioner
​.... facility 0..1Reference(Location | Organization)Servicing facility
​.... diagnosis
​..... diagnosis[x] 0..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityRequest 0..*CoverageEligibilityRequestCoverageEligibilityRequest resource
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... priority 1..1CodeableConceptDesired processing priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred.

... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested.


... patient Σ1..1Reference(Patient)Intended recipient of products and services
... serviced[x] 0..1Estimated date or dates of service
.... servicedDatedate
.... servicedPeriodPeriod
... created Σ1..1dateTimeCreation date
... enterer 1..1Reference(Practitioner | PractitionerRole)Author
... provider 1..1Reference(Practitioner | Organization)Party responsible for the request
... insurer Σ1..1Reference(Organization)Coverage issuer
... facility 0..1Reference(Location)Servicing facility
... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... information 1..1Reference(Resource)Data to be provided
.... appliesToAll 0..1booleanApplies to all items
... insurance 0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal 0..1booleanApplicable coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
... item 0..*BackboneElementItem to be evaluated for eligibiity
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... supportingInfoSequence 0..*positiveIntApplicable exception or supporting information
.... category 0..1CodeableConceptBenefit classification
Binding: ClaimServiceCategories (example): Benefit categories such as: oral, medical, vision etc.

.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: ClaimServiceCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptProduct 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..1Reference(Practitioner | PractitionerRole)Perfoming practitioner
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... facility 0..1Reference(Location | Organization)Servicing facility
.... diagnosis 0..*BackboneElementApplicable diagnosis
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... diagnosis[x] 0..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)
.... detail 0..*Reference(Resource)Product or service details

doco Documentation for this format

Differential View

This structure is derived from CoverageEligibilityRequest

NameFlagsCard.TypeDescription & Constraintsdoco
​.. CoverageEligibilityRequest 0..*CoverageEligibilityRequestCoverageEligibilityRequest resource
​... identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
​... priority 1..1CodeableConceptDesired processing priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred.

​... patient Σ1..1Reference(Patient)Intended recipient of products and services
​... provider 1..1Reference(Practitioner | Organization)Party responsible for the request
​... insurer Σ1..1Reference(Organization)Coverage issuer
​... insurance
​.... coverage 1..1Reference(Coverage)Insurance information
​... item
​.... category 0..1CodeableConceptBenefit classification
Binding: ClaimServiceCategories (example): Benefit categories such as: oral, medical, vision etc.

​.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: ClaimServiceCodes (example): Allowable service and product codes.

​.... provider 0..1Reference(Practitioner | PractitionerRole)Perfoming practitioner
​.... facility 0..1Reference(Location | Organization)Servicing facility
​.... diagnosis
​..... diagnosis[x] 0..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityRequest 0..*CoverageEligibilityRequestCoverageEligibilityRequest resource
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... priority 1..1CodeableConceptDesired processing priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred.

... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested.


... patient Σ1..1Reference(Patient)Intended recipient of products and services
... serviced[x] 0..1Estimated date or dates of service
.... servicedDatedate
.... servicedPeriodPeriod
... created Σ1..1dateTimeCreation date
... enterer 1..1Reference(Practitioner | PractitionerRole)Author
... provider 1..1Reference(Practitioner | Organization)Party responsible for the request
... insurer Σ1..1Reference(Organization)Coverage issuer
... facility 0..1Reference(Location)Servicing facility
... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... information 1..1Reference(Resource)Data to be provided
.... appliesToAll 0..1booleanApplies to all items
... insurance 0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal 0..1booleanApplicable coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
... item 0..*BackboneElementItem to be evaluated for eligibiity
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... supportingInfoSequence 0..*positiveIntApplicable exception or supporting information
.... category 0..1CodeableConceptBenefit classification
Binding: ClaimServiceCategories (example): Benefit categories such as: oral, medical, vision etc.

.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: ClaimServiceCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptProduct 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..1Reference(Practitioner | PractitionerRole)Perfoming practitioner
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... facility 0..1Reference(Location | Organization)Servicing facility
.... diagnosis 0..*BackboneElementApplicable diagnosis
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... diagnosis[x] 0..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

...... diagnosisCodeableConceptCodeableConcept
...... diagnosisReferenceReference(Condition)
.... detail 0..*Reference(Resource)Product or service details

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
CoverageEligibilityRequest.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
CoverageEligibilityRequest.statusrequiredFinancialResourceStatusCodes
CoverageEligibilityRequest.priorityexampleProcessPriorityCodes
CoverageEligibilityRequest.purposerequiredEligibilityRequestPurpose
CoverageEligibilityRequest.item.categoryexampleClaimServiceCategories
CoverageEligibilityRequest.item.productOrServiceexampleClaimServiceCodes
CoverageEligibilityRequest.item.modifierexampleModifierTypeCodes
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]exampleICD-10Codes

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()