CoverageEligibityResponse
Defines the ID Core constraints and extensions on the CoverageEligibilityResponse resource for the minimal set of data to communicate coverage information. It is usually used together with Coverage and CoverageEligibilityRequest.
Usage
This profile is used by providers and payors, insurers, to response the coverage information request, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics.
The primary uses of this resource is to support verification of electronic claims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.
URL
Type | URL |
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Canonical | https://fhir.kemkes.go.id/r4/StructureDefinition/CoverageEligibilityResponse |
Structure
Snapshot
CoverageEligibilityResponse | I | DomainResource | |
id | Σ | 0..1 | string |
meta | Σ | 0..1 | Meta |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
identifier | 0..* | Identifier | |
status | Σ ?! | 1..1 | codeBinding |
purpose | Σ | 1..* | codeBinding |
patient | Σ I | 1..1 | Reference(Patient) |
serviced[x] | 0..1 | ||
servicedDate | date | ||
servicedPeriod | Period | ||
created | Σ | 1..1 | dateTime |
requestor | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization) |
request | Σ I | 1..1 | Reference(CoverageEligibilityRequest) |
outcome | Σ | 1..1 | codeBinding |
disposition | 0..1 | string | |
insurer | Σ I | 1..1 | Reference(Organization) |
insurance | 0..* | BackboneElement | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
coverage | Σ I | 1..1 | Reference(Coverage) |
inforce | 0..1 | boolean | |
benefitPeriod | I | 0..1 | Period |
item | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
category | 0..1 | CodeableConcept | |
productOrService | 0..1 | CodeableConcept | |
modifier | 0..* | CodeableConcept | |
provider | I | 0..1 | Reference(Practitioner | PractitionerRole) |
excluded | 0..1 | boolean | |
name | 0..1 | string | |
description | 0..1 | string | |
network | 0..1 | CodeableConcept | |
unit | 0..1 | CodeableConcept | |
term | 0..1 | CodeableConcept | |
benefit | 0..* | BackboneElement | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
type | 1..1 | CodeableConcept | |
allowed[x] | 0..1 | ||
allowedUnsignedInt | unsignedInt | ||
allowedString | string | ||
allowedMoney | Money | ||
used[x] | 0..1 | ||
usedUnsignedInt | unsignedInt | ||
usedString | string | ||
usedMoney | Money | ||
authorizationRequired | 0..1 | boolean | |
authorizationSupporting | 0..* | CodeableConcept | |
authorizationUrl | 0..1 | uri | |
preAuthRef | 0..1 | string | |
form | 0..1 | CodeableConcept | |
error | 0..* | BackboneElement | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | 1..1 | CodeableConcept |
Examples
Dictionary
CoverageEligibilityResponse | |
Definition | This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource. |
Cardinality | 0...* |
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CoverageEligibilityResponse.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Cardinality | 0...1 |
Type | string |
Summary | True |
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. |
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. |
Cardinality | 0...1 |
Type | Meta |
Summary | True |
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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. |
Cardinality | 0...1 |
Type | uri |
Modifier | True |
Summary | True |
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. |
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CoverageEligibilityResponse.language | |
Definition | The base language in which the resource is written. |
Cardinality | 0...1 |
Type | code |
Binding | A human language. |
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). |
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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. |
Cardinality | 0...1 |
Type | Narrative |
Alias | narrative, 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. |
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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. |
Cardinality | 0...* |
Type | Resource |
Alias | inline 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. |
Mappings |
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CoverageEligibilityResponse.identifier | |
Definition | A unique identifier assigned to this coverage eligiblity request. |
Cardinality | 0...* |
Type | Identifier |
Requirements | Allows coverage eligibility requests to be distinguished and referenced. |
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CoverageEligibilityResponse.status | |
Definition | The status of the resource instance. |
Cardinality | 1...1 |
Type | code |
Binding | A code specifying the state of the resource instance. |
Modifier | True |
Summary | True |
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. |
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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. |
Cardinality | 1...* |
Type | code |
Binding | A code specifying the types of information being requested. |
Summary | True |
Requirements | To indicate the processing actions requested. |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
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CoverageEligibilityResponse.patient | |
Definition | The party who is the beneficiary of the supplied coverage and for whom eligibility is sought. |
Cardinality | 1...1 |
Type | Reference(Patient) |
Summary | True |
Requirements | Required to provide context and coverage validation. |
Comments | 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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CoverageEligibilityResponse.serviced[x] | |
Definition | The date or dates when the enclosed suite of services were performed or completed. |
Cardinality | 0...1 |
Type | date |
Requirements | Required to provide time context for the request. |
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CoverageEligibilityResponse.created | |
Definition | The date this resource was created. |
Cardinality | 1...1 |
Type | dateTime |
Summary | True |
Requirements | Need to record a timestamp for use by both the recipient and the issuer. |
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CoverageEligibilityResponse.requestor | |
Definition | The provider which is responsible for the request. |
Cardinality | 0...1 |
Type | Reference(Practitioner | PractitionerRole | Organization) |
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. |
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CoverageEligibilityResponse.request | |
Definition | Reference to the original request resource. |
Cardinality | 1...1 |
Type | Reference(CoverageEligibilityRequest) |
Summary | True |
Requirements | Needed to allow the response to be linked to the request. |
Comments | 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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CoverageEligibilityResponse.outcome | |
Definition | The outcome of the request processing. |
Cardinality | 1...1 |
Type | code |
Binding | The outcome of the processing. |
Summary | True |
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). |
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CoverageEligibilityResponse.disposition | |
Definition | A human readable description of the status of the adjudication. |
Cardinality | 0...1 |
Type | string |
Requirements | Provided for user display. |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
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CoverageEligibilityResponse.insurer | |
Definition | The Insurer who issued the coverage in question and is the author of the response. |
Cardinality | 1...1 |
Type | Reference(Organization) |
Summary | True |
Requirements | Need to identify the author. |
Comments | 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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CoverageEligibilityResponse.insurance | |
Definition | Financial instruments for reimbursement for the health care products and services. |
Cardinality | 0...* |
Type | BackboneElement |
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. |
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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. |
Cardinality | 0...1 |
Type | string |
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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. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, 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. |
Slicing | Unordered, Open, by url(Value) |
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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). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
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. |
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. |
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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. |
Cardinality | 1...1 |
Type | Reference(Coverage) |
Summary | True |
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system. |
Comments | 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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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. |
Cardinality | 0...1 |
Type | boolean |
Requirements | Needed to convey the answer to the eligibility validation request. |
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CoverageEligibilityResponse.insurance.benefitPeriod | |
Definition | The term of the benefits documented in this response. |
Cardinality | 0...1 |
Type | Period |
Requirements | Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. |
Comments | 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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CoverageEligibilityResponse.insurance.item | |
Definition | Benefits and optionally current balances, and authorization details by category or service. |
Cardinality | 0...* |
Type | BackboneElement |
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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. |
Cardinality | 0...1 |
Type | string |
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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. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, 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. |
Slicing | Unordered, Open, by url(Value) |
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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). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
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. |
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. |
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CoverageEligibilityResponse.insurance.item.category | |
Definition | Code to identify the general type of benefits under which products and services are provided. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Benefit categories such as: oral, medical, vision etc. |
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. |
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CoverageEligibilityResponse.insurance.item.productOrService | |
Definition | This contains the product, service, drug or other billing code for the item. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Allowable service and product codes. |
Alias | Drug Code, Bill Code, Service Code |
Requirements | Needed to convey the actual service or product for which eligibility is sought. |
Comments | Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). |
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CoverageEligibilityResponse.insurance.item.modifier | |
Definition | Item typification or modifiers codes to convey additional context for the product or service. |
Cardinality | 0...* |
Type | CodeableConcept |
Binding | Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. |
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. |
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CoverageEligibilityResponse.insurance.item.provider | |
Definition | The practitioner who is eligible for the provision of the product or service. |
Cardinality | 0...1 |
Type | Reference(Practitioner | PractitionerRole) |
Requirements | Needed to convey the eligible provider. |
Comments | 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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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. |
Cardinality | 0...1 |
Type | boolean |
Requirements | Needed to identify items that are specifically excluded from the coverage. |
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CoverageEligibilityResponse.insurance.item.name | |
Definition | A short name or tag for the benefit. |
Cardinality | 0...1 |
Type | string |
Requirements | Required to align with other plan names. |
Comments | For example: MED01, or DENT2. |
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CoverageEligibilityResponse.insurance.item.description | |
Definition | A richer description of the benefit or services covered. |
Cardinality | 0...1 |
Type | string |
Requirements | Needed for human readable reference. |
Comments | For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'. |
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CoverageEligibilityResponse.insurance.item.network | |
Definition | Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Code to classify in or out of network services. |
Requirements | Needed as in or out of network providers are treated differently under the coverage. |
Comments | 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. |
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CoverageEligibilityResponse.insurance.item.unit | |
Definition | Indicates if the benefits apply to an individual or to the family. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Unit covered/serviced - individual or family. |
Requirements | Needed for the understanding of the benefits. |
Comments | 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. |
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CoverageEligibilityResponse.insurance.item.term | |
Definition | The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Coverage unit - annual, lifetime. |
Requirements | Needed for the understanding of the benefits. |
Comments | 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. |
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CoverageEligibilityResponse.insurance.item.benefit | |
Definition | Benefits used to date. |
Cardinality | 0...* |
Type | BackboneElement |
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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. |
Cardinality | 0...1 |
Type | string |
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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. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, 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. |
Slicing | Unordered, Open, by url(Value) |
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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). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
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. |
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. |
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CoverageEligibilityResponse.insurance.item.benefit.type | |
Definition | Classification of benefit being provided. |
Cardinality | 1...1 |
Type | CodeableConcept |
Binding | Deductable, visits, co-pay, etc. |
Requirements | Needed to convey the nature of the benefit. |
Comments | For example: deductible, visits, benefit amount. |
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CoverageEligibilityResponse.insurance.item.benefit.allowed[x] | |
Definition | The quantity of the benefit which is permitted under the coverage. |
Cardinality | 0...1 |
Type | unsignedInt |
Requirements | Needed to convey the benefits offered under the coverage. |
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CoverageEligibilityResponse.insurance.item.benefit.used[x] | |
Definition | The quantity of the benefit which have been consumed to date. |
Cardinality | 0...1 |
Type | unsignedInt |
Requirements | Needed to convey the benefits consumed to date. |
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CoverageEligibilityResponse.insurance.item.authorizationRequired | |
Definition | A boolean flag indicating whether a preauthorization is required prior to actual service delivery. |
Cardinality | 0...1 |
Type | boolean |
Requirements | Needed to convey that preauthorization is required. |
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CoverageEligibilityResponse.insurance.item.authorizationSupporting | |
Definition | Codes or comments regarding information or actions associated with the preauthorization. |
Cardinality | 0...* |
Type | CodeableConcept |
Binding | Type of supporting information to provide with a preauthorization. |
Requirements | Needed to inform the provider of collateral materials or actions needed for preauthorization. |
Comments | 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. |
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CoverageEligibilityResponse.insurance.item.authorizationUrl | |
Definition | A web location for obtaining requirements or descriptive information regarding the preauthorization. |
Cardinality | 0...1 |
Type | uri |
Requirements | Needed to enable insurers to advise providers of informative information. |
Comments | see http://en.wikipedia.org/wiki/Uniform_resource_identifier |
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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. |
Cardinality | 0...1 |
Type | string |
Requirements | To provide any preauthorization reference for provider use. |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
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CoverageEligibilityResponse.form | |
Definition | A code for the form to be used for printing the content. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | The forms codes. |
Requirements | Needed to specify the specific form used for producing output for this response. |
Comments | May be needed to identify specific jurisdictional forms. |
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CoverageEligibilityResponse.error | |
Definition | Errors encountered during the processing of the request. |
Cardinality | 0...* |
Type | BackboneElement |
Requirements | Need to communicate processing issues to the requestor. |
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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. |
Cardinality | 0...1 |
Type | string |
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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. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, 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. |
Slicing | Unordered, Open, by url(Value) |
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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). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
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. |
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. |
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CoverageEligibilityResponse.error.code | |
Definition | An error code,from a specified code system, which details why the eligibility check could not be performed. |
Cardinality | 1...1 |
Type | CodeableConcept |
Binding | The error codes for adjudication processing. |
Requirements | Required to convey processing errors. |
Comments | 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. |
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