FHIR Implementation Guide for HCX
0.9.0 - CI Build

FHIR Implementation Guide for HCX - Local Development build (v0.9.0). See the Directory of published versions

Resource Profile: CoverageEligibilityResponse - Detailed Descriptions

Definitions for the CoverageEligibilityResponse resource profile.

Guidance on how to interpret the contents of this table can be found here.

1. CoverageEligibilityResponse
Definition

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

Control0..*
Summaryfalse
2. CoverageEligibilityResponse.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Summarytrue
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

3. CoverageEligibilityResponse.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Control0..1
TypeMeta
Summarytrue
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. CoverageEligibilityResponse.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue
Summarytrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. CoverageEligibilityResponse.language
Definition

The base language in which the resource is written.

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages A human language
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Summaryfalse
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. CoverageEligibilityResponse.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
TypeNarrative
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. CoverageEligibilityResponse.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

8. CoverageEligibilityResponse.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
9. CoverageEligibilityResponse.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. CoverageEligibilityResponse.identifier
Definition

A unique identifier assigned to this coverage eligiblity request.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..1
TypeIdentifier
Summaryfalse
Requirements

Allows coverage eligibility requests to be distinguished and referenced.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. CoverageEligibilityResponse.status
Definition

The status of the resource instance.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes A code specifying the state of the resource instance
Typecode
Is Modifiertrue
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. CoverageEligibilityResponse.purpose
Definition

Code to specify whether requesting: prior authorization requirements for some service categories or billing codes; benefits for coverages specified or discovered; discovery and return of coverages for the patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.

Control1..*
BindingThe codes SHALL be taken from EligibilityResponsePurpose A code specifying the types of information being requested
Typecode
Summarytrue
Requirements

To indicate the processing actions requested.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. CoverageEligibilityResponse.patient
Definition

The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.

Control1..1
TypeReference(Patient)
Summarytrue
Requirements

Required to provide context and coverage validation.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. CoverageEligibilityResponse.serviced[x]
Definition

The date or dates when the enclosed suite of services were performed or completed.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summaryfalse
Requirements

Required to provide time context for the request.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. CoverageEligibilityResponse.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Summarytrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. CoverageEligibilityResponse.requestor
Definition

The provider which is responsible for the request.

Control1..1
TypeReference(Practitioner|Organization)
Summaryfalse
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. CoverageEligibilityResponse.request
Definition

Reference to the original request resource.

Control1..1
TypeReference(CoverageEligibilityRequest)
Summarytrue
Requirements

Needed to allow the response to be linked to the request.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. CoverageEligibilityResponse.outcome
Definition

The outcome of the request processing.

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodes The outcome of the processing
Typecode
Summarytrue
Requirements

To advise the requestor of an overall processing outcome.

Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. CoverageEligibilityResponse.disposition
Definition

A human readable description of the status of the adjudication.

Control0..1
Typestring
Summaryfalse
Requirements

Provided for user display.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. CoverageEligibilityResponse.insurer
Definition

The Insurer who issued the coverage in question and is the author of the response.

Control1..1
TypeReference(Organization)
Summarytrue
Requirements

Need to identify the author.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. CoverageEligibilityResponse.insurance
Definition

Financial instruments for reimbursement for the health care products and services.

Control0..*
TypeBackboneElement
Summaryfalse
Requirements

There must be at least one coverage for which eligibility is requested.

Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. CoverageEligibilityResponse.insurance.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
Summaryfalse
23. CoverageEligibilityResponse.insurance.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
24. CoverageEligibilityResponse.insurance.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
25. CoverageEligibilityResponse.insurance.coverage
Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Control1..1
TypeReference(Coverage)
Summarytrue
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
26. CoverageEligibilityResponse.insurance.inforce
Definition

Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.

Control0..1
Typeboolean
Summaryfalse
Requirements

Needed to convey the answer to the eligibility validation request.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
27. CoverageEligibilityResponse.insurance.benefitPeriod
Definition

The term of the benefits documented in this response.

Control0..1
TypePeriod
Summaryfalse
Requirements

Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
28. CoverageEligibilityResponse.insurance.item
Definition

Benefits and optionally current balances, and authorization details by category or service.

Control0..*
TypeBackboneElement
Summaryfalse
InvariantsDefined on this element
ces-1: SHALL contain a category or a billcode but not both. (: category.exists() xor productOrService.exists())
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. CoverageEligibilityResponse.insurance.item.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
Summaryfalse
30. CoverageEligibilityResponse.insurance.item.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
31. CoverageEligibilityResponse.insurance.item.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
32. CoverageEligibilityResponse.insurance.item.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
BindingFor example codes, see ClaimServiceCategories Benefit categories such as: oral, medical, vision etc
TypeCodeableConcept
Summaryfalse
Requirements

Needed to convey the category of service or product for which eligibility is sought.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. CoverageEligibilityResponse.insurance.item.productOrService
Definition

This contains the product, service, drug or other billing code for the item.

Control0..1
BindingFor example codes, see ClaimServiceCodes Allowable service and product codes
TypeCodeableConcept
Summaryfalse
Requirements

Needed to convey the actual service or product for which eligibility is sought.

Alternate NamesDrug Code, Bill Code, Service Code
Comments

Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. CoverageEligibilityResponse.insurance.item.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
BindingFor example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
TypeCodeableConcept
Summaryfalse
Requirements

To support provision of the item or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
35. CoverageEligibilityResponse.insurance.item.provider
Definition

The practitioner who is eligible for the provision of the product or service.

Control0..1
TypeReference(Practitioner|PractitionerRole)
Summaryfalse
Requirements

Needed to convey the eligible provider.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
36. CoverageEligibilityResponse.insurance.item.excluded
Definition

True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

Control0..1
Typeboolean
Summaryfalse
Requirements

Needed to identify items that are specifically excluded from the coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
37. CoverageEligibilityResponse.insurance.item.name
Definition

A short name or tag for the benefit.

Control0..1
Typestring
Summaryfalse
Requirements

Required to align with other plan names.

Comments

For example: MED01, or DENT2.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
38. CoverageEligibilityResponse.insurance.item.description
Definition

A richer description of the benefit or services covered.

Control0..1
Typestring
Summaryfalse
Requirements

Needed for human readable reference.

Comments

For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
39. CoverageEligibilityResponse.insurance.item.network
Definition

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Control0..1
BindingFor example codes, see NetworkTypeCodes Code to classify in or out of network services
TypeCodeableConcept
Summaryfalse
Requirements

Needed as in or out of network providers are treated differently under the coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
40. CoverageEligibilityResponse.insurance.item.unit
Definition

Indicates if the benefits apply to an individual or to the family.

Control0..1
BindingFor example codes, see UnitTypeCodes Unit covered/serviced - individual or family
TypeCodeableConcept
Summaryfalse
Requirements

Needed for the understanding of the benefits.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
41. CoverageEligibilityResponse.insurance.item.term
Definition

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Control0..1
BindingFor example codes, see BenefitTermCodes Coverage unit - annual, lifetime
TypeCodeableConcept
Summaryfalse
Requirements

Needed for the understanding of the benefits.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
42. CoverageEligibilityResponse.insurance.item.benefit
Definition

Benefits used to date.

Control0..*
TypeBackboneElement
Summaryfalse
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
43. CoverageEligibilityResponse.insurance.item.benefit.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
Summaryfalse
44. CoverageEligibilityResponse.insurance.item.benefit.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
45. CoverageEligibilityResponse.insurance.item.benefit.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
46. CoverageEligibilityResponse.insurance.item.benefit.type
Definition

Classification of benefit being provided.

Control1..1
BindingFor example codes, see BenefitTypeCodes Deductable, visits, co-pay, etc
TypeCodeableConcept
Summaryfalse
Requirements

Needed to convey the nature of the benefit.

Comments

For example: deductible, visits, benefit amount.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
47. CoverageEligibilityResponse.insurance.item.benefit.allowed[x]
Definition

The quantity of the benefit which is permitted under the coverage.

Control0..1
TypeChoice of: unsignedInt, string, Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summaryfalse
Requirements

Needed to convey the benefits offered under the coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
48. CoverageEligibilityResponse.insurance.item.benefit.used[x]
Definition

The quantity of the benefit which have been consumed to date.

Control0..1
TypeChoice of: unsignedInt, string, Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summaryfalse
Requirements

Needed to convey the benefits consumed to date.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
49. CoverageEligibilityResponse.insurance.item.authorizationRequired
Definition

A boolean flag indicating whether a preauthorization is required prior to actual service delivery.

Control0..1
Typeboolean
Summaryfalse
Requirements

Needed to convey that preauthorization is required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
50. CoverageEligibilityResponse.insurance.item.authorizationSupporting
Definition

Codes or comments regarding information or actions associated with the preauthorization.

Control0..*
BindingFor example codes, see CoverageEligibilityResponseAuthSupportCodes Type of supporting information to provide with a preauthorization
TypeCodeableConcept
Summaryfalse
Requirements

Needed to inform the provider of collateral materials or actions needed for preauthorization.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
51. CoverageEligibilityResponse.insurance.item.authorizationUrl
Definition

A web location for obtaining requirements or descriptive information regarding the preauthorization.

Control0..1
Typeuri
Summaryfalse
Requirements

Needed to enable insurers to advise providers of informative information.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
52. CoverageEligibilityResponse.preAuthRef
Definition

A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.

Control0..1
Typestring
Summaryfalse
Requirements

To provide any preauthorization reference for provider use.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
53. CoverageEligibilityResponse.form
Definition

A code for the form to be used for printing the content.

Control0..1
BindingFor example codes, see Form Codes The forms codes
TypeCodeableConcept
Summaryfalse
Requirements

Needed to specify the specific form used for producing output for this response.

Comments

May be needed to identify specific jurisdictional forms.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
54. CoverageEligibilityResponse.error
Definition

Errors encountered during the processing of the request.

Control0..*
TypeBackboneElement
Summaryfalse
Requirements

Need to communicate processing issues to the requestor.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
55. CoverageEligibilityResponse.error.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
Summaryfalse
56. CoverageEligibilityResponse.error.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
57. CoverageEligibilityResponse.error.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
58. CoverageEligibilityResponse.error.code
Definition

An error code,from a specified code system, which details why the eligibility check could not be performed.

Control1..1
BindingFor example codes, see Adjudication Error Codes The error codes for adjudication processing
TypeCodeableConcept
Summaryfalse
Requirements

Required to convey processing errors.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))