CoverageEligibilityRequest

ResourceFinancial · SupportTrial useMaturity 2

The CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.

StructureSearch parametersHL7 specificationStructureDefinition JSON

Tested supportFull test results →

Backends

PostgreSQLElasticsearch

Interactions

CreateReadUpdatePatchDelete

Search

7 of 7 parameters tested

Structure

Show inherited elements (20)

Element	Card.	Type	Description
identifier	0..*	Identifier	Business Identifier for coverage eligiblity request
statusRequired?!Σ	1..1	code	active | cancelled | draft | entered-in-errorBinding (required): fm-status
priority	0..1	CodeableConcept	Desired processing priorityBinding (example): process-priority
purposeRequiredΣ	1..*	code	auth-requirements | benefits | discovery | validationBinding (required): eligibilityrequest-purpose
patientRequiredΣ	1..1	Reference(Patient)	Intended recipient of products and services
serviced[x]	0..1	date | Period	Estimated date or dates of service
createdRequiredΣ	1..1	dateTime	Creation date
enterer	0..1	Reference(Practitioner | PractitionerRole)	Author
provider	0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
insurerRequiredΣ	1..1	Reference(Organization)	Coverage issuer
facility	0..1	Reference(Location)	Servicing facility
supportingInfo	0..*	BackboneElement	Supporting information
sequenceRequired	1..1	positiveInt	Information instance identifier
informationRequired	1..1	Reference(Resource)	Data to be provided
appliesToAll	0..1	boolean	Applies to all items
insurance	0..*	BackboneElement	Patient insurance information
focal	0..1	boolean	Applicable coverage
coverageRequired	1..1	Reference(Coverage)	Insurance information
businessArrangement	0..1	string	Additional provider contract number
item	0..*	BackboneElement	Item to be evaluated for eligibiity
supportingInfoSequence	0..*	positiveInt	Applicable exception or supporting information
category	0..1	CodeableConcept	Benefit classificationBinding (example): ex-benefitcategory
productOrService	0..1	CodeableConcept	Billing, service, product, or drug codeBinding (example): service-uscls
modifier	0..*	CodeableConcept	Product or service billing modifiersBinding (example): claim-modifiers
provider	0..1	Reference(Practitioner | PractitionerRole)	Perfoming practitioner
quantity	0..1	Quantity	Count of products or services
unitPrice	0..1	Money	Fee, charge or cost per item
facility	0..1	Reference(Location | Organization)	Servicing facility
diagnosis	0..*	BackboneElement	Applicable diagnosis
diagnosis[x]	0..1	CodeableConcept | Reference(Condition)	Nature of illness or problemBinding (example): icd-10
detail	0..*	Reference(Resource)	Product or service details

Σ in _summary results · ?! modifier element · 1.. required · inherited elements in grey

Search parameters

Query with GET [base]/CoverageEligibilityRequest?[parameter]=[value]. Type decides which modifiers and prefixes apply, see search features.

Parameter	Type	Description	PG	ES
created	date	The creation date for the EOB CoverageEligibilityRequest.created
enterer	reference	The party who is responsible for the request CoverageEligibilityRequest.enterer
facility	reference	Facility responsible for the goods and services CoverageEligibilityRequest.facility
identifier	token	The business identifier of the Eligibility CoverageEligibilityRequest.identifier
patient	reference	The reference to the patient CoverageEligibilityRequest.patient
provider	reference	The reference to the provider CoverageEligibilityRequest.provider
status	token	The status of the EligibilityRequest CoverageEligibilityRequest.status

PG: PostgreSQL, ES: Elasticsearch. passes its TestScript checks, fails, not tested yet.

Common parameters on every resource (8)

_haste-health-author	reference	The author of the resource
_id	token	Logical id of this artifact
_lastUpdated	date	When the resource version last changed
_profile	uri	Profiles this resource claims to conform to
_security	token	Security Labels applied to this resource
_source	uri	Identifies where the resource comes from
_tag	token	Tags applied to this resource
_type	token	Derived from the R4B Definition