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:

Profile Content

Simplifier link for the profile: CoverageEligibilityResponse (MSP-LRA)

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patientS Σ I1..1Reference(Patient)
servicedDatedate
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requestorI0..1Reference(Practitioner | PractitionerRole | Organization)
requestS Σ I1..1Reference(CoverageEligibilityRequest)
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insurerS Σ I1..1Reference(Organization)
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LRA Interaction Support

Search

  1. Search by Coverage Eligibility

  2. 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

    • 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'
    • Business identifiers are considered Personally Identifiable Information (PII) and must be protected appropriately.

    Date of Service

    • 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
     

    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

  3. Search by Patient and include Coverage Eligibility

  4. 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:

    • PHN as the identifier.

    • ‘_has’ & '_revinclude' search parameters within the patient query request.

    Notes:

    • 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).

    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

  5. Eligibility Result

  6. 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
  7. Eligibility Response Codes

  8. 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