This page is part of the IHE ITI Finance and Insurance Services (v1.0.0: Publication) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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Resource Profile: FAIS CoverageEligibilityRequest Profile

The FAIS CoverageEligibilityRequest profile for submitting coverage eligibility requests.

Usage:

• Use this Resource Profile: FAIS CoverageEligibilityRequest Bundle Profile
• Refer to this Resource Profile: FAIS CoverageEligibilityResponse Profile
• Examples for this Resource Profile: CoverageEligibilityRequest/ex-check-coverage-2 and CoverageEligibilityRequest/ex-check-coverage

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from CoverageEligibilityRequest

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest			CoverageEligibilityRequest
implicitRules		0..0
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
statusReason		0..1	CodeableConcept	Request Status Reason URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/request-statusReason
modifierExtension		0..0
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
statusReason		0..1	CodeableConcept	Request Status Reason URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/request-statusReason
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
purpose	Σ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
created	Σ	1..1	dateTime	Creation date
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.purpose	required	EligibilityRequestPurpose http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
statusReason		0..1	CodeableConcept	Request Status Reason URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/request-statusReason
identifier		0..*	Identifier	Business Identifier for coverage eligiblity request
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
priority		0..1	CodeableConcept	Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred.
purpose	Σ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
serviced[x]		0..1		Estimated date or dates of service
servicedDate			date
servicedPeriod			Period
created	Σ	1..1	dateTime	Creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author
provider		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
facility		0..1	Reference(Location)	Servicing facility
supportingInfo		0..*	BackboneElement	Supporting information
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
sequence		1..1	positiveInt	Information instance identifier
information		1..1	Reference(Resource)	Data to be provided
appliesToAll		0..1	boolean	Applies to all items
insurance		0..*	BackboneElement	Patient insurance information
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
focal		0..1	boolean	Applicable coverage
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
item		0..*	BackboneElement	Item to be evaluated for eligibiity
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
supportingInfoSequence		0..*	positiveInt	Applicable exception or supporting information
category		0..1	CodeableConcept	Benefit classification 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)	Perfoming practitioner
quantity		0..1	SimpleQuantity	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
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
diagnosis[x]		0..1		Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
detail		0..*	Reference(Resource)	Product or service details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
CoverageEligibilityRequest.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
CoverageEligibilityRequest.purpose	required	EligibilityRequestPurpose http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.item.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
CoverageEligibilityRequest.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
CoverageEligibilityRequest.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard

This structure is derived from CoverageEligibilityRequest

Summary

Prohibited: 2 elements

Extensions

This structure refers to these extensions:

• https://profiles.ihe.net/ITI/FAIS/StructureDefinition/request-statusReason

Differential View

This structure is derived from CoverageEligibilityRequest

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest			CoverageEligibilityRequest
implicitRules		0..0
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
statusReason		0..1	CodeableConcept	Request Status Reason URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/request-statusReason
modifierExtension		0..0
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
statusReason		0..1	CodeableConcept	Request Status Reason URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/request-statusReason
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
purpose	Σ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
created	Σ	1..1	dateTime	Creation date
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.purpose	required	EligibilityRequestPurpose http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 from the FHIR Standard

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityRequest		0..*	CoverageEligibilityRequest	CoverageEligibilityRequest resource
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
statusReason		0..1	CodeableConcept	Request Status Reason URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/request-statusReason
identifier		0..*	Identifier	Business Identifier for coverage eligiblity request
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
priority		0..1	CodeableConcept	Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred.
purpose	Σ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
serviced[x]		0..1		Estimated date or dates of service
servicedDate			date
servicedPeriod			Period
created	Σ	1..1	dateTime	Creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author
provider		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
facility		0..1	Reference(Location)	Servicing facility
supportingInfo		0..*	BackboneElement	Supporting information
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
sequence		1..1	positiveInt	Information instance identifier
information		1..1	Reference(Resource)	Data to be provided
appliesToAll		0..1	boolean	Applies to all items
insurance		0..*	BackboneElement	Patient insurance information
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
focal		0..1	boolean	Applicable coverage
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
item		0..*	BackboneElement	Item to be evaluated for eligibiity
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
supportingInfoSequence		0..*	positiveInt	Applicable exception or supporting information
category		0..1	CodeableConcept	Benefit classification 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)	Perfoming practitioner
quantity		0..1	SimpleQuantity	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
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
diagnosis[x]		0..1		Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
detail		0..*	Reference(Resource)	Product or service details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityRequest.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
CoverageEligibilityRequest.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
CoverageEligibilityRequest.purpose	required	EligibilityRequestPurpose http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.0.1 from the FHIR Standard
CoverageEligibilityRequest.item.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
CoverageEligibilityRequest.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
CoverageEligibilityRequest.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
CoverageEligibilityRequest.item.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard

This structure is derived from CoverageEligibilityRequest

Summary

Prohibited: 2 elements

Extensions

This structure refers to these extensions:

• https://profiles.ihe.net/ITI/FAIS/StructureDefinition/request-statusReason

Other representations of profile: CSV, Excel, Schematron