FHIR Release 3 (STU)

This page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R3 R2

Financial Management Work GroupMaturity Level: 2 Trial UseCompartments: Practitioner

Detailed Descriptions for the elements in the EligibilityResponse resource.

EligibilityResponse
Definition

This resource provides eligibility and plan details from the processing of an Eligibility resource.

Control1..1
EligibilityResponse.identifier
Definition

The Response business identifier.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
EligibilityResponse.status
Definition

The status of the resource instance.

Control0..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue
Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the response as not currently valid.

EligibilityResponse.created
Definition

The date when the enclosed suite of services were performed or completed.

Control0..1
TypedateTime
EligibilityResponse.requestProvider
Definition

The practitioner who is responsible for the services rendered to the patient.

Control0..1
TypeReference(Practitioner)
EligibilityResponse.requestOrganization
Definition

The organization which is responsible for the services rendered to the patient.

Control0..1
TypeReference(Organization)
EligibilityResponse.request
Definition

Original request resource reference.

Control0..1
TypeReference(EligibilityRequest)
EligibilityResponse.outcome
Definition

Transaction status: error, complete.

Control0..1
Terminology BindingRemittanceOutcome (Required)
TypeCodeableConcept
EligibilityResponse.disposition
Definition

A description of the status of the adjudication.

Control0..1
Typestring
EligibilityResponse.insurer
Definition

The Insurer who produced this adjudicated response.

Control0..1
TypeReference(Organization)
EligibilityResponse.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.

Control0..1
Typeboolean
EligibilityResponse.insurance
Definition

The insurer may provide both the details for the requested coverage as well as details for additional coverages known to the insurer.

Control0..*
EligibilityResponse.insurance.coverage
Definition

A suite of updated or additional Coverages from the Insurer.

Control0..1
TypeReference(Coverage)
EligibilityResponse.insurance.contract
Definition

The contract resource which may provide more detailed information.

Control0..1
TypeReference(Contract)
EligibilityResponse.insurance.benefitBalance
Definition

Benefits and optionally current balances by Category.

Control0..*
EligibilityResponse.insurance.benefitBalance.category
Definition

Dental, Vision, Medical, Pharmacy, Rehab etc.

Control1..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
EligibilityResponse.insurance.benefitBalance.subCategory
Definition

Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.

Control0..1
Terminology BindingBenefit SubCategory Codes (Example)
TypeCodeableConcept
EligibilityResponse.insurance.benefitBalance.excluded
Definition

True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.

Control0..1
Typeboolean
EligibilityResponse.insurance.benefitBalance.name
Definition

A short name or tag for the benefit, for example MED01, or DENT2.

Control0..1
Typestring
EligibilityResponse.insurance.benefitBalance.description
Definition

A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.

Control0..1
Typestring
EligibilityResponse.insurance.benefitBalance.network
Definition

Network designation.

Control0..1
Terminology BindingNetwork Type Codes (Example)
TypeCodeableConcept
EligibilityResponse.insurance.benefitBalance.unit
Definition

Unit designation: individual or family.

Control0..1
Terminology BindingUnit Type Codes (Example)
TypeCodeableConcept
EligibilityResponse.insurance.benefitBalance.term
Definition

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.

Control0..1
Terminology BindingBenefit Term Codes (Example)
TypeCodeableConcept
EligibilityResponse.insurance.benefitBalance.financial
Definition

Benefits Used to date.

Control0..*
EligibilityResponse.insurance.benefitBalance.financial.type
Definition

Deductable, visits, benefit amount.

Control1..1
Terminology BindingBenefit Type Codes (Example)
TypeCodeableConcept
EligibilityResponse.insurance.benefitBalance.financial.allowed[x]
Definition

Benefits allowed.

Control0..1
TypeunsignedInt|string|Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
EligibilityResponse.insurance.benefitBalance.financial.used[x]
Definition

Benefits used.

Control0..1
TypeunsignedInt|Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
EligibilityResponse.form
Definition

The form to be used for printing the content.

Control0..1
Terminology BindingForm Codes (Example)
TypeCodeableConcept
EligibilityResponse.error
Definition

Mutually exclusive with Services Provided (Item).

Control0..*
EligibilityResponse.error.code
Definition

An error code,from a specified code system, which details why the eligibility check could not be performed.

Control1..1
Terminology BindingAdjudication Error Codes (Example)
TypeCodeableConcept