Finance and Insurance Service (FAIS)
1.0.0-comment - ballot
This page is part of the IHE ITI Finance and Insurance Services (v1.0.0-comment: Publication Ballot 1) 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
Official URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/IHE.FAIS.CoverageEligibilityResponse | Version: 1.0.0-comment | |||
Active as of 2024-08-07 | Computable Name: FAISCoverageEligibilityResponse |
The FAIS CoverageEligibilityResponse profile to be used as the response to the FAIS CoverageEligibilityRequest $submit
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CoverageEligibilityResponse
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CoverageEligibilityResponse | CoverageEligibilityResponse | |||
implicitRules | 0..0 | |||
modifierExtension | 0..0 | |||
request | 1..1 | Reference(FAIS CoverageEligibilityRequest Profile) | Eligibility request reference | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CoverageEligibilityResponse | 0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |
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: EligibilityResponsePurpose (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 | Response creation date |
request | Σ | 1..1 | Reference(FAIS CoverageEligibilityRequest Profile) | Eligibility request reference |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing. |
insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer |
Documentation for this format |
Path | Conformance | ValueSet | URI |
CoverageEligibilityResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
CoverageEligibilityResponse.purpose | required | EligibilityResponsePurposehttp://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1 from the FHIR Standard | |
CoverageEligibilityResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
CoverageEligibilityResponse | 0..* | CoverageEligibilityResponse | CoverageEligibilityResponse 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.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
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. | ||||
purpose | Σ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (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 | Response creation date | ||||
requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |||||
request | Σ | 1..1 | Reference(FAIS CoverageEligibilityRequest Profile) | Eligibility request reference | ||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing. | ||||
disposition | 0..1 | string | Disposition Message | |||||
insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer | ||||
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 | ||||
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
inforce | 0..1 | boolean | Coverage inforce indicator | |||||
benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
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 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 | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
benefit | 0..* | BackboneElement | Benefit Summary | |||||
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. | |||||
allowed[x] | 0..1 | Benefits allowed | ||||||
allowedUnsignedInt | unsignedInt | |||||||
allowedString | string | |||||||
allowedMoney | Money | |||||||
used[x] | 0..1 | Benefits used | ||||||
usedUnsignedInt | unsignedInt | |||||||
usedString | string | |||||||
usedMoney | Money | |||||||
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 | Processing errors | |||||
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 | ||||
code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing. | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
CoverageEligibilityResponse.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
CoverageEligibilityResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
CoverageEligibilityResponse.purpose | required | EligibilityResponsePurposehttp://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1 from the FHIR Standard | ||||
CoverageEligibilityResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.unit | example | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.term | example | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.benefit.type | example | BenefitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.authorizationSupporting | example | CoverageEligibilityResponseAuthSupportCodeshttp://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support from the FHIR Standard | ||||
CoverageEligibilityResponse.form | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | ||||
CoverageEligibilityResponse.error.code | example | Adjudication Error Codeshttp://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard |
This structure is derived from CoverageEligibilityResponse
Differential View
This structure is derived from CoverageEligibilityResponse
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CoverageEligibilityResponse | CoverageEligibilityResponse | |||
implicitRules | 0..0 | |||
modifierExtension | 0..0 | |||
request | 1..1 | Reference(FAIS CoverageEligibilityRequest Profile) | Eligibility request reference | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CoverageEligibilityResponse | 0..* | CoverageEligibilityResponse | CoverageEligibilityResponse resource | |
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: EligibilityResponsePurpose (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 | Response creation date |
request | Σ | 1..1 | Reference(FAIS CoverageEligibilityRequest Profile) | Eligibility request reference |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing. |
insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer |
Documentation for this format |
Path | Conformance | ValueSet | URI |
CoverageEligibilityResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
CoverageEligibilityResponse.purpose | required | EligibilityResponsePurposehttp://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1 from the FHIR Standard | |
CoverageEligibilityResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
CoverageEligibilityResponse | 0..* | CoverageEligibilityResponse | CoverageEligibilityResponse 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.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
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. | ||||
purpose | Σ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (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 | Response creation date | ||||
requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the request | |||||
request | Σ | 1..1 | Reference(FAIS CoverageEligibilityRequest Profile) | Eligibility request reference | ||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The outcome of the processing. | ||||
disposition | 0..1 | string | Disposition Message | |||||
insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer | ||||
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 | ||||
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
inforce | 0..1 | boolean | Coverage inforce indicator | |||||
benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
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 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 | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
benefit | 0..* | BackboneElement | Benefit Summary | |||||
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. | |||||
allowed[x] | 0..1 | Benefits allowed | ||||||
allowedUnsignedInt | unsignedInt | |||||||
allowedString | string | |||||||
allowedMoney | Money | |||||||
used[x] | 0..1 | Benefits used | ||||||
usedUnsignedInt | unsignedInt | |||||||
usedString | string | |||||||
usedMoney | Money | |||||||
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 | Processing errors | |||||
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 | ||||
code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing. | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
CoverageEligibilityResponse.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
CoverageEligibilityResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
CoverageEligibilityResponse.purpose | required | EligibilityResponsePurposehttp://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.0.1 from the FHIR Standard | ||||
CoverageEligibilityResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.unit | example | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.term | example | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.benefit.type | example | BenefitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard | ||||
CoverageEligibilityResponse.insurance.item.authorizationSupporting | example | CoverageEligibilityResponseAuthSupportCodeshttp://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support from the FHIR Standard | ||||
CoverageEligibilityResponse.form | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | ||||
CoverageEligibilityResponse.error.code | example | Adjudication Error Codeshttp://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard |
This structure is derived from CoverageEligibilityResponse
Other representations of profile: CSV, Excel, Schematron