FHIR Implementation Guide for HCX
0.8.0 - CI Build

FHIR Implementation Guide for HCX - Local Development build (v0.8.0). See the Directory of published versions

Resource Profile: HCX Coverage Eligibility Response

Defining URL:https://ig.hcxprotocol.io/v0.8/StructureDefinition-CoverageEligibilityResponse.html
Version:0.8.0
Name:CoverageEligibilityResponse
Status:Draft as of 2021-08-16 09:29:23+1100 (Standards Status: Trial Use)
Definition:

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

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

The official URL for this profile is: 

https://ig.hcxprotocol.io/v0.8/StructureDefinition-CoverageEligibilityResponse.html

Formal Views of Profile Content

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

This structure is derived from CoverageEligibilityResponse

NameFlagsCard.TypeDescription & Constraintsdoco
​.. CoverageEligibilityResponse 0..*CoverageEligibilityResponseCoverageEligibilityResponse resource
​... identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
​... patient Σ1..1Reference(Patient)Intended recipient of products and services
​... requestor 1..1Reference(Practitioner | Organization)Party responsible for the request
​... insurer Σ1..1Reference(Organization)Coverage issuer
​... insurance
​.... coverage Σ1..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)Performing practitioner

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..*CoverageEligibilityResponseCoverageEligibilityResponse 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.

... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (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..1dateTimeResponse creation date
... requestor 1..1Reference(Practitioner | Organization)Party responsible for the request
... request Σ1..1Reference(CoverageEligibilityRequest)Eligibility request reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... disposition 0..1stringDisposition Message
... insurer Σ1..1Reference(Organization)Coverage issuer
... 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
.... coverage Σ1..1Reference(Coverage)Insurance information
.... inforce 0..1booleanCoverage inforce indicator
.... benefitPeriod 0..1PeriodWhen the benefits are applicable
.... item C0..*BackboneElementBenefits and authorization details
..... 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
..... 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)Performing practitioner
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit or services covered
..... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

..... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

..... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

..... benefit 0..*BackboneElementBenefit Summary
...... 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
...... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedStringstring
....... usedMoneyMoney
..... authorizationRequired 0..1booleanAuthorization required flag
..... authorizationSupporting 0..*CodeableConceptType of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


..... authorizationUrl 0..1uriPreauthorization requirements endpoint
... preAuthRef 0..1stringPreauthorization reference
... form 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... error 0..*BackboneElementProcessing errors
.... 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
.... code 1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.


doco Documentation for this format

Differential View

This structure is derived from CoverageEligibilityResponse

NameFlagsCard.TypeDescription & Constraintsdoco
​.. CoverageEligibilityResponse 0..*CoverageEligibilityResponseCoverageEligibilityResponse resource
​... identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
​... patient Σ1..1Reference(Patient)Intended recipient of products and services
​... requestor 1..1Reference(Practitioner | Organization)Party responsible for the request
​... insurer Σ1..1Reference(Organization)Coverage issuer
​... insurance
​.... coverage Σ1..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)Performing practitioner

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..*CoverageEligibilityResponseCoverageEligibilityResponse 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.

... purpose Σ1..*codeauth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (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..1dateTimeResponse creation date
... requestor 1..1Reference(Practitioner | Organization)Party responsible for the request
... request Σ1..1Reference(CoverageEligibilityRequest)Eligibility request reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... disposition 0..1stringDisposition Message
... insurer Σ1..1Reference(Organization)Coverage issuer
... 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
.... coverage Σ1..1Reference(Coverage)Insurance information
.... inforce 0..1booleanCoverage inforce indicator
.... benefitPeriod 0..1PeriodWhen the benefits are applicable
.... item C0..*BackboneElementBenefits and authorization details
..... 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
..... 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)Performing practitioner
..... excluded 0..1booleanExcluded from the plan
..... name 0..1stringShort name for the benefit
..... description 0..1stringDescription of the benefit or services covered
..... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

..... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

..... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

..... benefit 0..*BackboneElementBenefit Summary
...... 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
...... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

...... allowed[x] 0..1Benefits allowed
....... allowedUnsignedIntunsignedInt
....... allowedStringstring
....... allowedMoneyMoney
...... used[x] 0..1Benefits used
....... usedUnsignedIntunsignedInt
....... usedStringstring
....... usedMoneyMoney
..... authorizationRequired 0..1booleanAuthorization required flag
..... authorizationSupporting 0..*CodeableConceptType of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


..... authorizationUrl 0..1uriPreauthorization requirements endpoint
... preAuthRef 0..1stringPreauthorization reference
... form 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... error 0..*BackboneElementProcessing errors
.... 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
.... code 1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.


doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
CoverageEligibilityResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
CoverageEligibilityResponse.statusrequiredFinancialResourceStatusCodes
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
CoverageEligibilityResponse.insurance.item.categoryexampleClaimServiceCategories
CoverageEligibilityResponse.insurance.item.productOrServiceexampleClaimServiceCodes
CoverageEligibilityResponse.insurance.item.modifierexampleModifierTypeCodes
CoverageEligibilityResponse.insurance.item.networkexampleNetworkTypeCodes
CoverageEligibilityResponse.insurance.item.unitexampleUnitTypeCodes
CoverageEligibilityResponse.insurance.item.termexampleBenefitTermCodes
CoverageEligibilityResponse.insurance.item.benefit.typeexampleBenefitTypeCodes
CoverageEligibilityResponse.insurance.item.authorizationSupportingexampleCoverageEligibilityResponseAuthSupportCodes
CoverageEligibilityResponse.formexampleForm Codes
CoverageEligibilityResponse.error.codeexampleAdjudication Error Codes

Constraints

IdGradePath(s)DetailsRequirements
ces-1errorCoverageEligibilityResponse.insurance.itemSHALL contain a category or a billcode but not both.
: category.exists() xor productOrService.exists()
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()