0.1.0 - ci-build

kenyaClaimsIG - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: SHACoverageEligibilityResponse

Official URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/SHACoverageEligibilityResponse Version: 0.1.0
Draft as of 2024-09-06 Computable Name: SHACoverageEligibilityResponse

An example of a CoverageEligibilityResponse profile

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CoverageEligibilityResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id 1..1 id A logical identifier for the messageHeader resource.
... meta 1..1 Meta Metadata about a resource
.... profile 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
.... siteEligibility 0..* CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
... status 1..1 code Financial Resource Status Code. Must use the fixed value 'active'
Required Pattern: active
... purpose 1..* code EligibilityResponsePurpose
... patient 1..1 Reference(SHAPatient) Intended recipient of products and services. A reference Patient resource
... Slices for serviced[x] 0..1 date, Period Estimated date or dates of service
Slice: Unordered, Open by type:$this
.... serviced[x]:servicedDate 0..1 date The date or dates when the enclosed suite of services were performed or completed.
.... serviced[x]:servicedPeriod 0..1 Period The period when the enclosed suite of services were performed or completed.
... created 1..1 dateTime Creation date of this CoverageEligibilityRequest
... request 1..1 Reference(SHACoverageEligibilityRequest) Eligibility request reference. A reference to the CoverageEligibilityRequest message
... outcome 1..1 code Payer processing outcome.
... disposition 0..1 string A human readable description of the status of the adjudication.
... insurer 1..1 Reference(SHAOrganization) Coverage issuer. A reference to the payor organization license issed by the regulator and maintained in the registry. Use the reference.identifier for well know identifiers.
... insurance 0..* BackboneElement Financial instruments for reimbursement for the health care products and services.
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... siteEligibility 0..1 CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
.... coverage 1..1 Reference(SHACoverage) Insurance information. A Reference to the insurance coverage resource
.... inforce 1..1 boolean A flag to indicate if the insurance coverage supplied is expected to be inforce as of the service date supplied or today if no service date supplied.
.... benefitPeriod
..... start 1..1 dateTime start date of the benefits
..... end 1..1 dateTime end date of the benefits
.... item
..... category 0..1 CodeableConcept Benefit classification. Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
..... excluded 0..1 boolean Indicates whether the benefit is excluded by the policy.
..... network 1..1 CodeableConcept In or out of network (Contracted of not contracted)
..... unit 1..1 CodeableConcept Individual or family
..... term 1..1 CodeableConcept Annual or lifetime
..... benefit 0..* BackboneElement Term for limites such as per day, annual or lifetime
...... Slices for allowed[x] 0..1 unsignedInt, string, Money Benefits allowed
Slice: Unordered, Open by type:$this
....... allowed[x]:allowedUnsignedInt 0..1 unsignedInt Benefits allowed
....... allowed[x]:allowedString 0..1 string Benefits allowed
....... allowed[x]:allowedMoney 0..1 Money Benefits allowed
...... Slices for used[x] 0..1 unsignedInt, string, Money Benefits used
Slice: Unordered, Open by type:$this
....... used[x]:usedUnsignedInt 0..1 unsignedInt Benefits used
....... used[x]:usedString 0..1 string Benefits used
....... used[x]:usedMoney 0..1 Money Benefits used
... error 0..* BackboneElement Errors encountered during the processing of the request
.... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression
.... code 1..1 CodeableConcept An error code,from a specified code system, which details why the eligibility check could not be performed

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id Σ 1..1 id A logical identifier for the messageHeader resource.
... meta Σ 1..1 Meta Metadata about a resource
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
.... siteEligibility 0..* CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 Identifier A business unique identifier for the CoverageEligibilityResponse resource.
... status ?!Σ 1..1 code Financial Resource Status Code. Must use the fixed value 'active'
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... purpose Σ 1..* code EligibilityResponsePurpose
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.


... patient Σ 1..1 Reference(SHAPatient) Intended recipient of products and services. A reference Patient resource
... Slices for serviced[x] 0..1 Estimated date or dates of service
Slice: Unordered, Closed by type:$this
.... servicedDate date
.... servicedPeriod Period
.... serviced[x]:servicedDate 0..1 date The date or dates when the enclosed suite of services were performed or completed.
.... serviced[x]:servicedPeriod 0..1 Period The period when the enclosed suite of services were performed or completed.
... created Σ 1..1 dateTime Creation date of this CoverageEligibilityRequest
... request Σ 1..1 Reference(SHACoverageEligibilityRequest) Eligibility request reference. A reference to the CoverageEligibilityRequest message
... outcome Σ 1..1 code Payer processing outcome.
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... disposition 0..1 string A human readable description of the status of the adjudication.
... insurer Σ 1..1 Reference(SHAOrganization) Coverage issuer. A reference to the payor organization license issed by the regulator and maintained in the registry. Use the reference.identifier for well know identifiers.
... insurance 0..* BackboneElement Financial instruments for reimbursement for the health care products and services.
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... siteEligibility 0..1 CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage Σ 1..1 Reference(SHACoverage) Insurance information. A Reference to the insurance coverage resource
.... inforce 1..1 boolean A flag to indicate if the insurance coverage supplied is expected to be inforce as of the service date supplied or today if no service date supplied.
... error 0..* BackboneElement Errors encountered during the processing of the request
.... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept An error code,from a specified code system, which details why the eligibility check could not be performed
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
CoverageEligibilityResponse.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageEligibilityResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageEligibilityResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCoverageEligibilityResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCoverageEligibilityResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageEligibilityResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id Σ 1..1 id A logical identifier for the messageHeader resource.
... meta Σ 1..1 Meta Metadata about a resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
.... siteEligibility 0..* CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 Identifier A business unique identifier for the CoverageEligibilityResponse resource.
... status ?!Σ 1..1 code Financial Resource Status Code. Must use the fixed value 'active'
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... purpose Σ 1..* code EligibilityResponsePurpose
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.


... patient Σ 1..1 Reference(SHAPatient) Intended recipient of products and services. A reference Patient resource
... Slices for serviced[x] 0..1 Estimated date or dates of service
Slice: Unordered, Closed by type:$this
.... servicedDate date
.... servicedPeriod Period
.... serviced[x]:servicedDate 0..1 date The date or dates when the enclosed suite of services were performed or completed.
.... serviced[x]:servicedPeriod 0..1 Period The period when the enclosed suite of services were performed or completed.
... created Σ 1..1 dateTime Creation date of this CoverageEligibilityRequest
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request Σ 1..1 Reference(SHACoverageEligibilityRequest) Eligibility request reference. A reference to the CoverageEligibilityRequest message
... outcome Σ 1..1 code Payer processing outcome.
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... disposition 0..1 string A human readable description of the status of the adjudication.
... insurer Σ 1..1 Reference(SHAOrganization) Coverage issuer. A reference to the payor organization license issed by the regulator and maintained in the registry. Use the reference.identifier for well know identifiers.
... insurance 0..* BackboneElement Financial instruments for reimbursement for the health care products and services.
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... siteEligibility 0..1 CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage Σ 1..1 Reference(SHACoverage) Insurance information. A Reference to the insurance coverage resource
.... inforce 1..1 boolean A flag to indicate if the insurance coverage supplied is expected to be inforce as of the service date supplied or today if no service date supplied.
.... benefitPeriod 0..1 Period When the benefits are applicable
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣC 1..1 dateTime start date of the benefits
..... end ΣC 1..1 dateTime end date of the benefits
.... item C 0..* BackboneElement Benefits and authorization details
ces-1: SHALL contain a category or a billcode but not both.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 0..1 CodeableConcept Benefit classification. Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.

..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Indicates whether the benefit is excluded by the policy.
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 1..1 CodeableConcept In or out of network (Contracted of not contracted)
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

..... unit 1..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

..... term 1..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

..... benefit 0..* BackboneElement Term for limites such as per day, annual or lifetime
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

...... Slices for allowed[x] 0..1 Benefits allowed
Slice: Unordered, Closed by type:$this
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
....... allowed[x]:allowedUnsignedInt 0..1 unsignedInt Benefits allowed
....... allowed[x]:allowedString 0..1 string Benefits allowed
....... allowed[x]:allowedMoney 0..1 Money Benefits allowed
...... Slices for used[x] 0..1 Benefits used
Slice: Unordered, Closed by type:$this
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
....... used[x]:usedUnsignedInt 0..1 unsignedInt Benefits used
....... used[x]:usedString 0..1 string Benefits used
....... used[x]:usedMoney 0..1 Money Benefits used
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... error 0..* BackboneElement Errors encountered during the processing of the request
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept An error code,from a specified code system, which details why the eligibility check could not be performed
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
CoverageEligibilityResponse.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
CoverageEligibilityResponse.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
CoverageEligibilityResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
CoverageEligibilityResponse.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupportingexampleCoverageEligibilityResponseAuthSupportCodes
http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support
from the FHIR Standard
CoverageEligibilityResponse.formexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
CoverageEligibilityResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ces-1errorCoverageEligibilityResponse.insurance.itemSHALL contain a category or a billcode but not both.
: category.exists() xor productOrService.exists()
dom-2errorCoverageEligibilityResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageEligibilityResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCoverageEligibilityResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCoverageEligibilityResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageEligibilityResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from CoverageEligibilityResponse

Summary

Mandatory: 4 elements(6 nested mandatory elements)

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of CoverageEligibilityResponse.serviced[x]
  • The element 1 is sliced based on the value of CoverageEligibilityResponse.insurance.item.benefit.allowed[x]
  • The element 1 is sliced based on the value of CoverageEligibilityResponse.insurance.item.benefit.used[x]

Differential View

This structure is derived from CoverageEligibilityResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id 1..1 id A logical identifier for the messageHeader resource.
... meta 1..1 Meta Metadata about a resource
.... profile 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
.... siteEligibility 0..* CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
... status 1..1 code Financial Resource Status Code. Must use the fixed value 'active'
Required Pattern: active
... purpose 1..* code EligibilityResponsePurpose
... patient 1..1 Reference(SHAPatient) Intended recipient of products and services. A reference Patient resource
... Slices for serviced[x] 0..1 date, Period Estimated date or dates of service
Slice: Unordered, Open by type:$this
.... serviced[x]:servicedDate 0..1 date The date or dates when the enclosed suite of services were performed or completed.
.... serviced[x]:servicedPeriod 0..1 Period The period when the enclosed suite of services were performed or completed.
... created 1..1 dateTime Creation date of this CoverageEligibilityRequest
... request 1..1 Reference(SHACoverageEligibilityRequest) Eligibility request reference. A reference to the CoverageEligibilityRequest message
... outcome 1..1 code Payer processing outcome.
... disposition 0..1 string A human readable description of the status of the adjudication.
... insurer 1..1 Reference(SHAOrganization) Coverage issuer. A reference to the payor organization license issed by the regulator and maintained in the registry. Use the reference.identifier for well know identifiers.
... insurance 0..* BackboneElement Financial instruments for reimbursement for the health care products and services.
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... siteEligibility 0..1 CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
.... coverage 1..1 Reference(SHACoverage) Insurance information. A Reference to the insurance coverage resource
.... inforce 1..1 boolean A flag to indicate if the insurance coverage supplied is expected to be inforce as of the service date supplied or today if no service date supplied.
.... benefitPeriod
..... start 1..1 dateTime start date of the benefits
..... end 1..1 dateTime end date of the benefits
.... item
..... category 0..1 CodeableConcept Benefit classification. Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
..... excluded 0..1 boolean Indicates whether the benefit is excluded by the policy.
..... network 1..1 CodeableConcept In or out of network (Contracted of not contracted)
..... unit 1..1 CodeableConcept Individual or family
..... term 1..1 CodeableConcept Annual or lifetime
..... benefit 0..* BackboneElement Term for limites such as per day, annual or lifetime
...... Slices for allowed[x] 0..1 unsignedInt, string, Money Benefits allowed
Slice: Unordered, Open by type:$this
....... allowed[x]:allowedUnsignedInt 0..1 unsignedInt Benefits allowed
....... allowed[x]:allowedString 0..1 string Benefits allowed
....... allowed[x]:allowedMoney 0..1 Money Benefits allowed
...... Slices for used[x] 0..1 unsignedInt, string, Money Benefits used
Slice: Unordered, Open by type:$this
....... used[x]:usedUnsignedInt 0..1 unsignedInt Benefits used
....... used[x]:usedString 0..1 string Benefits used
....... used[x]:usedMoney 0..1 Money Benefits used
... error 0..* BackboneElement Errors encountered during the processing of the request
.... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression
.... code 1..1 CodeableConcept An error code,from a specified code system, which details why the eligibility check could not be performed

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id Σ 1..1 id A logical identifier for the messageHeader resource.
... meta Σ 1..1 Meta Metadata about a resource
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
.... siteEligibility 0..* CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 Identifier A business unique identifier for the CoverageEligibilityResponse resource.
... status ?!Σ 1..1 code Financial Resource Status Code. Must use the fixed value 'active'
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... purpose Σ 1..* code EligibilityResponsePurpose
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.


... patient Σ 1..1 Reference(SHAPatient) Intended recipient of products and services. A reference Patient resource
... Slices for serviced[x] 0..1 Estimated date or dates of service
Slice: Unordered, Closed by type:$this
.... servicedDate date
.... servicedPeriod Period
.... serviced[x]:servicedDate 0..1 date The date or dates when the enclosed suite of services were performed or completed.
.... serviced[x]:servicedPeriod 0..1 Period The period when the enclosed suite of services were performed or completed.
... created Σ 1..1 dateTime Creation date of this CoverageEligibilityRequest
... request Σ 1..1 Reference(SHACoverageEligibilityRequest) Eligibility request reference. A reference to the CoverageEligibilityRequest message
... outcome Σ 1..1 code Payer processing outcome.
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... disposition 0..1 string A human readable description of the status of the adjudication.
... insurer Σ 1..1 Reference(SHAOrganization) Coverage issuer. A reference to the payor organization license issed by the regulator and maintained in the registry. Use the reference.identifier for well know identifiers.
... insurance 0..* BackboneElement Financial instruments for reimbursement for the health care products and services.
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... siteEligibility 0..1 CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage Σ 1..1 Reference(SHACoverage) Insurance information. A Reference to the insurance coverage resource
.... inforce 1..1 boolean A flag to indicate if the insurance coverage supplied is expected to be inforce as of the service date supplied or today if no service date supplied.
... error 0..* BackboneElement Errors encountered during the processing of the request
.... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept An error code,from a specified code system, which details why the eligibility check could not be performed
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
CoverageEligibilityResponse.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageEligibilityResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageEligibilityResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCoverageEligibilityResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCoverageEligibilityResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageEligibilityResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id Σ 1..1 id A logical identifier for the messageHeader resource.
... meta Σ 1..1 Meta Metadata about a resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
.... siteEligibility 0..* CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 Identifier A business unique identifier for the CoverageEligibilityResponse resource.
... status ?!Σ 1..1 code Financial Resource Status Code. Must use the fixed value 'active'
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... purpose Σ 1..* code EligibilityResponsePurpose
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.


... patient Σ 1..1 Reference(SHAPatient) Intended recipient of products and services. A reference Patient resource
... Slices for serviced[x] 0..1 Estimated date or dates of service
Slice: Unordered, Closed by type:$this
.... servicedDate date
.... servicedPeriod Period
.... serviced[x]:servicedDate 0..1 date The date or dates when the enclosed suite of services were performed or completed.
.... serviced[x]:servicedPeriod 0..1 Period The period when the enclosed suite of services were performed or completed.
... created Σ 1..1 dateTime Creation date of this CoverageEligibilityRequest
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request Σ 1..1 Reference(SHACoverageEligibilityRequest) Eligibility request reference. A reference to the CoverageEligibilityRequest message
... outcome Σ 1..1 code Payer processing outcome.
Binding: ClaimProcessingCodes (required): The outcome of the processing.

... disposition 0..1 string A human readable description of the status of the adjudication.
... insurer Σ 1..1 Reference(SHAOrganization) Coverage issuer. A reference to the payor organization license issed by the regulator and maintained in the registry. Use the reference.identifier for well know identifiers.
... insurance 0..* BackboneElement Financial instruments for reimbursement for the health care products and services.
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... siteEligibility 0..1 CodeableConcept SiteEligibility
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/site-eligibility
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage Σ 1..1 Reference(SHACoverage) Insurance information. A Reference to the insurance coverage resource
.... inforce 1..1 boolean A flag to indicate if the insurance coverage supplied is expected to be inforce as of the service date supplied or today if no service date supplied.
.... benefitPeriod 0..1 Period When the benefits are applicable
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣC 1..1 dateTime start date of the benefits
..... end ΣC 1..1 dateTime end date of the benefits
.... item C 0..* BackboneElement Benefits and authorization details
ces-1: SHALL contain a category or a billcode but not both.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 0..1 CodeableConcept Benefit classification. Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.

..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Indicates whether the benefit is excluded by the policy.
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 1..1 CodeableConcept In or out of network (Contracted of not contracted)
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

..... unit 1..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

..... term 1..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

..... benefit 0..* BackboneElement Term for limites such as per day, annual or lifetime
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

...... Slices for allowed[x] 0..1 Benefits allowed
Slice: Unordered, Closed by type:$this
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
....... allowed[x]:allowedUnsignedInt 0..1 unsignedInt Benefits allowed
....... allowed[x]:allowedString 0..1 string Benefits allowed
....... allowed[x]:allowedMoney 0..1 Money Benefits allowed
...... Slices for used[x] 0..1 Benefits used
Slice: Unordered, Closed by type:$this
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
....... used[x]:usedUnsignedInt 0..1 unsignedInt Benefits used
....... used[x]:usedString 0..1 string Benefits used
....... used[x]:usedMoney 0..1 Money Benefits used
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... error 0..* BackboneElement Errors encountered during the processing of the request
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept An error code,from a specified code system, which details why the eligibility check could not be performed
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
CoverageEligibilityResponse.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
CoverageEligibilityResponse.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
CoverageEligibilityResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
CoverageEligibilityResponse.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.purposerequiredEligibilityResponsePurpose
http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupportingexampleCoverageEligibilityResponseAuthSupportCodes
http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support
from the FHIR Standard
CoverageEligibilityResponse.formexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
CoverageEligibilityResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ces-1errorCoverageEligibilityResponse.insurance.itemSHALL contain a category or a billcode but not both.
: category.exists() xor productOrService.exists()
dom-2errorCoverageEligibilityResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageEligibilityResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCoverageEligibilityResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCoverageEligibilityResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageEligibilityResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from CoverageEligibilityResponse

Summary

Mandatory: 4 elements(6 nested mandatory elements)

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of CoverageEligibilityResponse.serviced[x]
  • The element 1 is sliced based on the value of CoverageEligibilityResponse.insurance.item.benefit.allowed[x]
  • The element 1 is sliced based on the value of CoverageEligibilityResponse.insurance.item.benefit.used[x]

 

Other representations of profile: CSV, Excel, Schematron