Profile: CoverageEligibilityResponse (MSP)
Overview
Health Insurance British Columbia (HIBC) and the Medical Service Plan (MSP) Eligiblity team has created a new Eligiblity service for PHSA, called the PHSA Eligibility Service. This service aims to provide the LRA Platform's client applications to query a combination of eligibility and patient information from HIBC and Client Registry provincial data sources respectively.Please refer to the LRA Configuration page for information on authentication, authorization, environment, and endpoint details.
Example Usage Scenarios
The following are example usage scenarios for this profile:
- Query for Coverage Eligibility information using Patient's PHN (limited to BC PHN only): Example Response - Search by Coverage Eligiblity
- Query for Patient based on PHN number and include Coverage Eligibility information: Example Response - Search by Patient Identifier
Profile Content
Simplifier link for the profile: CoverageEligibilityResponse (MSP-LRA)
LRAMSPCoverageEligibilityResponse (CoverageEligibilityResponse) | I | CoverageEligibilityResponse | There are no (further) constraints on this element Element idCoverageEligibilityResponse CoverageEligibilityResponse resource DefinitionThis resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCoverageEligibilityResponse.meta Metadata about the resource DefinitionThe 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCoverageEligibilityResponse.implicitRules A set of rules under which this content was created DefinitionA 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. 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.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCoverageEligibilityResponse.language Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idCoverageEligibilityResponse.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idCoverageEligibilityResponse.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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extension | I | 0..* | Extension | Element idCoverageEligibilityResponse.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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dispositionCode | S I | 0..1 | Extension(code) | Element idCoverageEligibilityResponse.extension:dispositionCode Optional Extensions Element Alternate namesextensions, user content DefinitionA code from MSP identifying the disposition of coverage 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. http://phsa.ca/fhir/StructureDefinition/ca-bc-lra-msp-extension-DispositionCode Constraints
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coverageCancelReasonLegacyCode | S I | 0..1 | Extension(code) | Element idCoverageEligibilityResponse.extension:coverageCancelReasonLegacyCode Optional Extensions Element Alternate namesextensions, user content DefinitionA legacy code from MSP identifying the reason cancellation of coverage 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. http://phsa.ca/fhir/StructureDefinition/ca-bc-lra-msp-extension-CoverageCancelReasonLegacyCode Constraints
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informationDetails | S I | 0..* | Extension(CodeableConcept) | Element idCoverageEligibilityResponse.extension:informationDetails Optional Extensions Element Alternate namesextensions, user content DefinitionAdditional codes and explanations from a coverage eligibility request 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. http://phsa.ca/fhir/StructureDefinition/ca-bc-lra-msp-extension-InformationDetails Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | 0..* | Identifier | There are no (further) constraints on this element Element idCoverageEligibilityResponse.identifier Business Identifier for coverage eligiblity request DefinitionA unique identifier assigned to this coverage eligiblity request. Allows coverage eligibility requests to be distinguished and referenced.
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status | Σ ?! | 1..1 | codeBindingFixed Value | Element idCoverageEligibilityResponse.status active | cancelled | draft | entered-in-error DefinitionThe status of the resource instance. 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'. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the resource instance.
active
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purpose | Σ | 1..* | codeBindingFixed Value | Element idCoverageEligibilityResponse.purpose auth-requirements | benefits | discovery | validation DefinitionCode 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. To indicate the processing actions requested. Note that FHIR strings SHALL NOT exceed 1MB in size A code specifying the types of information being requested.
validation
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patient | S Σ I | 1..1 | Reference(Patient) | There are no (further) constraints on this element Element idCoverageEligibilityResponse.patient Intended recipient of products and services DefinitionThe party who is the beneficiary of the supplied coverage and for whom eligibility is sought. Required to provide context and coverage validation. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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serviced[x] | S | 0..1 | There are no (further) constraints on this element Element idCoverageEligibilityResponse.serviced[x] Estimated date or dates of service DefinitionThe date or dates when the enclosed suite of services were performed or completed. Required to provide time context for the request.
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servicedDate | date | Data type | ||
created | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idCoverageEligibilityResponse.created Response creation date DefinitionThe date this resource was created. Need to record a timestamp for use by both the recipient and the issuer.
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requestor | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idCoverageEligibilityResponse.requestor Party responsible for the request DefinitionThe provider which is responsible for the request. 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. Reference(Practitioner | PractitionerRole | Organization) Constraints
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request | S Σ I | 1..1 | Reference(CoverageEligibilityRequest) | There are no (further) constraints on this element Element idCoverageEligibilityResponse.request Eligibility request reference DefinitionReference to the original request resource. Needed to allow the response to be linked to the request. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(CoverageEligibilityRequest) Constraints
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outcome | S Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idCoverageEligibilityResponse.outcome queued | complete | error | partial DefinitionThe outcome of the request processing. To advise the requestor of an overall processing outcome. 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). The outcome of the processing.
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disposition | S | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.disposition Disposition Message DefinitionA human readable description of the status of the adjudication. Provided for user display. Note that FHIR strings SHALL NOT exceed 1MB in size
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insurer | S Σ I | 1..1 | Reference(Organization) | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurer Coverage issuer DefinitionThe Insurer who issued the coverage in question and is the author of the response. Need to identify the author. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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insurance | S | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance Patient insurance information DefinitionFinancial instruments for reimbursement for the health care products and services. There must be at least one coverage for which eligibility is requested. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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coverage | Σ I | 1..1 | Reference(Coverage) | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.coverage Insurance information DefinitionReference 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. Required to allow the adjudicator to locate the correct policy and history within their information system. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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inforce | S | 0..1 | boolean | Element idCoverageEligibilityResponse.insurance.inforce Beneficiary's coverage status DefinitionIndicates whether the beneficiary has an active MSP coverage. Needed to convey the answer to the eligibility validation request.
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benefitPeriod | I | 0..1 | Period | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.benefitPeriod When the benefits are applicable DefinitionThe term of the benefits documented in this response. Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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item | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item Benefits and authorization details DefinitionBenefits and optionally current balances, and authorization details by category or service.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.category Benefit classification DefinitionCode to identify the general type of benefits under which products and services are provided. Needed to convey the category of service or product for which eligibility is sought. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. Benefit categories such as: oral, medical, vision etc.
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productOrService | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.productOrService Billing, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code DefinitionThis contains the product, service, drug or other billing code for the item. Needed to convey the actual service or product for which eligibility is sought. Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.modifier Product or service billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support provision of the item or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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provider | I | 0..1 | Reference(Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.provider Performing practitioner DefinitionThe practitioner who is eligible for the provision of the product or service. Needed to convey the eligible provider. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole) Constraints
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excluded | 0..1 | boolean | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.excluded Excluded from the plan DefinitionTrue if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage. Needed to identify items that are specifically excluded from the coverage.
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name | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.name Short name for the benefit DefinitionA short name or tag for the benefit. Required to align with other plan names. For example: MED01, or DENT2.
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description | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.description Description of the benefit or services covered DefinitionA richer description of the benefit or services covered. Needed for human readable reference. For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
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network | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.network In or out of network DefinitionIs a flag to indicate whether the benefits refer to in-network providers or out-of-network providers. Needed as in or out of network providers are treated differently under the coverage. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Code to classify in or out of network services.
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unit | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.unit Individual or family DefinitionIndicates if the benefits apply to an individual or to the family. Needed for the understanding of the benefits. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Unit covered/serviced - individual or family.
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term | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.term Annual or lifetime DefinitionThe term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. Needed for the understanding of the benefits. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Coverage unit - annual, lifetime.
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benefit | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.benefit Benefit Summary DefinitionBenefits used to date.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.benefit.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.benefit.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.benefit.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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type | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.benefit.type Benefit classification DefinitionClassification of benefit being provided. Needed to convey the nature of the benefit. For example: deductible, visits, benefit amount. Deductable, visits, co-pay, etc.
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allowed[x] | 0..1 | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.benefit.allowed[x] Benefits allowed DefinitionThe quantity of the benefit which is permitted under the coverage. Needed to convey the benefits offered under the coverage.
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allowedUnsignedInt | unsignedInt | There are no (further) constraints on this element Data type | ||
allowedString | string | There are no (further) constraints on this element Data type | ||
allowedMoney | Money | There are no (further) constraints on this element Data type | ||
used[x] | 0..1 | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.benefit.used[x] Benefits used DefinitionThe quantity of the benefit which have been consumed to date. Needed to convey the benefits consumed to date.
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usedUnsignedInt | unsignedInt | There are no (further) constraints on this element Data type | ||
usedString | string | There are no (further) constraints on this element Data type | ||
usedMoney | Money | There are no (further) constraints on this element Data type | ||
authorizationRequired | 0..1 | boolean | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.authorizationRequired Authorization required flag DefinitionA boolean flag indicating whether a preauthorization is required prior to actual service delivery. Needed to convey that preauthorization is required.
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authorizationSupporting | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.authorizationSupporting Type of required supporting materials DefinitionCodes or comments regarding information or actions associated with the preauthorization. Needed to inform the provider of collateral materials or actions needed for preauthorization. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Type of supporting information to provide with a preauthorization.
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authorizationUrl | 0..1 | uri | There are no (further) constraints on this element Element idCoverageEligibilityResponse.insurance.item.authorizationUrl Preauthorization requirements endpoint DefinitionA web location for obtaining requirements or descriptive information regarding the preauthorization. Needed to enable insurers to advise providers of informative information. see http://en.wikipedia.org/wiki/Uniform_resource_identifier
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preAuthRef | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.preAuthRef Preauthorization reference DefinitionA reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred. To provide any preauthorization reference for provider use. Note that FHIR strings SHALL NOT exceed 1MB in size
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form | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.form Printed form identifier DefinitionA code for the form to be used for printing the content. Needed to specify the specific form used for producing output for this response. May be needed to identify specific jurisdictional forms. The forms codes.
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error | 0..* | BackboneElement | Element idCoverageEligibilityResponse.error Processing errors DefinitionErrors encountered during the processing of the request. Need to communicate processing issues to the requestor. Used to return error details in case of any validation failures or issues during the eligibility check.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverageEligibilityResponse.error.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.error.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverageEligibilityResponse.error.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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code | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverageEligibilityResponse.error.code Error code detailing processing issues DefinitionAn error code,from a specified code system, which details why the eligibility check could not be performed. Required to convey processing errors. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The error codes for adjudication processing.
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LRA Interaction Support
Search
-
Search by Coverage Eligibility
- The Patient Identifier refers to the client whose eligibility information needs to be verified, and it is limited to BC PHNs only.
-
Where
[patient.identifier]
is a token with both system and value specified (system|value
):- System is
'https://fhir.infoway-inforoute.ca/NamingSystem/ca-bc-patient-healthcare-id'
- Value is a
'BC PHN'
- System is
- Business identifiers are considered Personally Identifiable Information (PII) and must be protected appropriately.
- The Service Date is the date for which the eligibility status needs to be verified. This date can be in the past or the future.
-
Service Date uses a custom search parameter called
‘serviced-date’
. -
Where
[serviced-date]
is a string with a valid Date of Service specified, which must be a valid date in the following format:YYYY-MM-DD
-
Search by Patient and include Coverage Eligibility
PHN as the
identifier
.‘_has’
&'_revinclude'
search parameters within the patient query request.- Requires Client Registry (EMPI) access.
- Searching by demographic information such as first name, last name, and date of birth is not supported.
- If no patient is found in the Client Registry (EMPI), then NO Coverage Eligibility information is returned in the message (Success or Error).
-
Eligibility Result
-
Eligibility Response Codes
Using this method, HIBC will be queried directly for the MSP Eligibility information. This query must include a patient identifier
within the URL AND a service date
.
Patient Identifier
Date of Service
Query Structure:GET[base]/CoverageEligibilityResponse?patient.identifier=[system|value]&serviced-date=[date of service]
Query Example:GET[base]/CoverageEligibilityResponse?patient.identifier=https://fhir.infoway-inforoute.ca/NamingSystem/ca-bc-patient-healthcare-id|9892651498&serviced-date=2024-04-02
Example Response: Search by Coverage Eligiblity
This method queries the Client Registry (EMPI) AND HIBC (MSP Eligibility) for the Patient and Coverage Eligibility information respectively. The following must be utilized to fulfil this request:
Notes:
Query Structure:GET[base]/Patient?identifier=[identifier]&_has:CoverageEligibilityResponse:patient:serviced-date=[date of service]&_revinclude=CoverageEligibilityResponse:patient
Query Example:GET[base]/Patient?identifier=https://fhir.infoway-inforoute.ca/NamingSystem/ca-bc-patient-healthcare-id|9892651498&_has:CoverageEligibilityResponse:patient:serviced-date=2024-04-02&_revinclude=CoverageEligibilityResponse:patient
Example Response: Search by Patient Identifier
The Patient's MSP Eligiblity Result is returned in the following FHIR elements:
FHIR Path | Value | Description |
---|---|---|
CoverageEligibilityResponse.insurance.inforce |
true | Beneficiary has an active coverage |
CoverageEligibilityResponse.insurance.inforce |
false | Beneficiary does not have active coverage |
HIBC returns the following Response Codes for additional information:
FHIR Path | Code | Code Description |
---|---|---|
CoverageEligibilityResponse.outcome |
COMPLETE | QUERY SUCCESSFUL |
CoverageEligibilityResponse.outcome |
ERROR | QUERY UNSUCCESSFUL |
CoverageEligibilityResponse.extension:dispositionCode |
“HJMB001I” | SUCCESSFULLY COMPLETED |
CoverageEligibilityResponse.extension:dispositionCode |
“HRPB059E” | PHN INVALID |
CoverageEligibilityResponse.extension:dispositionCode |
“ELIG0003” | INVALID DATE OF SERVICE. |
CoverageEligibilityResponse.extension:dispositionCode |
“ELIG1001” | REQUEST SUBMITTED DOES NOT MATCH THE SCHEMA DEFINITION |
CoverageEligibilityResponse.extension:dispositionCode |
“HNHR511W” | INPUT PHN WAS MERGED |
CoverageEligibilityResponse.extension:dispositionCode |
“ELIG0010” | PERSON PHN DOES NOT EXIST |
CoverageEligibilityResponse.extension:coverageCancelReasonLegacyCode |
“DEAD” | Deceased |
CoverageEligibilityResponse.extension:coverageCancelReasonLegacyCode |
“RESQ” | Residency in Question |
CoverageEligibilityResponse.extension:coverageCancelReasonLegacyCode |
“OOPM” | Moved out of province or out of country |
CoverageEligibilityResponse.extension:coverageCancelReasonLegacyCode |
“LOSC” | Lost Contact |
CoverageEligibilityResponse.extension:coverageCancelReasonLegacyCode |
“RQST” | Date of Arrival, Urgent Need or Emergency coverage |
CoverageEligibilityResponse.extension:coverageCancelReasonLegacyCode |
“OO” | Opted Out |
CoverageEligibilityResponse.extension:coverageCancelReasonLegacyCode |
“CHAF” | Armed Forces |
CoverageEligibilityResponse.extension:informationDetails |
“CINST” | CLIENT INSTRUCTION TEXT |
CoverageEligibilityResponse.extension:informationDetails |
“CCARD_M1” | BC SERVICES CARD MESSAGE 1 |
CoverageEligibilityResponse.extension:informationDetails |
“CCARD_M2” | BC SERVICES CARD MESSAGE 2 |
CoverageEligibilityResponse.extension:informationDetails |
“CCARD_M3” | BC SERVICES CARD MESSAGE 3 |