{
"description": "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.",
"_filename": "StructureDefinition-CoverageEligibilityRequest.json",
"package_name": "hl7.fhir.core",
"date": "2018-08-19T21:48:56+10:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2018-08-19T21:48:56.559+10:00"
},
"publisher": "Health Level Seven International (Financial Management)",
"fhirVersion": "3.5.0",
"name": "CoverageEligibilityRequest",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern",
"identity": "w5"
}, {
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping",
"identity": "v2"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
} ],
"abstract": false,
"type": "CoverageEligibilityRequest",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "3.5.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString": "Financial.Support"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueString": "Trial Use"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
} ],
"snapshot": {
"element": [ {
"constraint": [ {
"key": "dom-2",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-4",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-3",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource",
"xpath": "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
"source": "DomainResource",
"severity": "error",
"expression": "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()"
}, {
"key": "dom-6",
"human": "A resource should have narrative for robust management",
"xpath": "exists(f:text/h:div)",
"source": "DomainResource",
"severity": "warning",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice",
"valueBoolean": true
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation",
"valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a guman readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time."
} ],
"expression": "text.div.exists()"
}, {
"key": "dom-5",
"human": "If a resource is contained in another resource, it SHALL NOT have a security label",
"xpath": "not(exists(f:contained/*/f:meta/f:security))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.meta.security.empty()"
} ],
"path": "CoverageEligibilityRequest",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "CoverageEligibilityRequest resource",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Request",
"identity": "workflow"
} ],
"max": "*",
"id": "CoverageEligibilityRequest",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.id",
"min": 0,
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"isModifier": false,
"short": "Logical id of this artifact",
"type": [ {
"code": "id"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.id",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.meta",
"min": 0,
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.",
"isModifier": false,
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.implicitRules",
"min": 0,
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.",
"isModifier": true,
"short": "A set of rules under which this content was created",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.implicitRules",
"comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"isModifier": false,
"short": "Language of the resource content",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A human language."
},
"max": "1",
"id": "CoverageEligibilityRequest.language",
"comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"base": {
"max": "1",
"min": 0,
"path": "Resource.language"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.text",
"min": 0,
"definition": "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"isModifier": false,
"short": "Text summary of the resource, for human interpretation",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "CoverageEligibilityRequest.text",
"comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.",
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.contained",
"min": 0,
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"isModifier": false,
"short": "Contained, inline Resources",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "CoverageEligibilityRequest.contained",
"comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "CoverageEligibilityRequest.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "CoverageEligibilityRequest.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.identifier",
"min": 0,
"definition": "The Response business identifier.",
"isModifier": false,
"short": "Business Identifier",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.identifier",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.identifier"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.status",
"requirements": "This element is labeled as a modifier because the status contains codes that mark the request as not currently valid.",
"min": 0,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Request.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "EligibilityRequestStatus"
} ],
"description": "A code specifying the state of the resource instance."
},
"max": "1",
"id": "CoverageEligibilityRequest.status",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.status"
},
"isModifierReason": "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.priority",
"min": 0,
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"isModifier": false,
"short": "Desired processing priority",
"mapping": [ {
"map": "Request.priority",
"identity": "workflow"
}, {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/process-priority",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
} ],
"description": "The timeliness with which processing is required: STAT, normal, Deferred."
},
"max": "1",
"id": "CoverageEligibilityRequest.priority",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.priority"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.purpose",
"min": 1,
"definition": "Specify whether requesting: prior authorization requirements for some service categories or billing codes; benefits for coverages specified or discovered; discovery and return of coverages for th patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.",
"isModifier": false,
"short": "auth-requirements | benefits | discovery | validation",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "EligibilityRequestPurpose"
} ],
"description": "A code specifying the types of information being requested."
},
"max": "*",
"id": "CoverageEligibilityRequest.purpose",
"base": {
"max": "*",
"min": 1,
"path": "CoverageEligibilityRequest.purpose"
},
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.patient",
"min": 0,
"definition": "Patient Resource.",
"isModifier": false,
"short": "The subject of the Products and Services",
"mapping": [ {
"map": "Request.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.patient",
"comment": "1..1.",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.patient"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.serviced[x]",
"min": 0,
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"isModifier": false,
"short": "Estimated date or dates of Service",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.serviced[x]",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.serviced[x]"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.created",
"min": 0,
"definition": "The date when this resource was created.",
"isModifier": false,
"short": "Creation date",
"mapping": [ {
"map": "Request.authoredOn",
"identity": "workflow"
}, {
"map": "FiveWs.recorded",
"identity": "w5"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.created",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.created"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.enterer",
"min": 0,
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"isModifier": false,
"short": "Author",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.enterer",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.enterer"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.provider",
"min": 0,
"definition": "The provider who is responsible for the services rendered to the patient.",
"isModifier": false,
"short": "Responsible provider",
"mapping": [ {
"map": "Request.requester",
"identity": "workflow"
}, {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.provider",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.provider"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurer",
"min": 0,
"definition": "The Insurer who is target of the request.",
"isModifier": false,
"short": "Target",
"mapping": [ {
"map": "Request.performer",
"identity": "workflow"
}, {
"map": "FiveWs.who",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.insurer",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.insurer"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.facility",
"min": 0,
"definition": "Facility where the services were provided.",
"isModifier": false,
"short": "Servicing Facility",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.facility",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.facility"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.supportingInformation",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"isModifier": false,
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Information"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.supportingInformation",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.supportingInformation"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInformation.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.supportingInformation.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInformation.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "CoverageEligibilityRequest.supportingInformation.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInformation.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "CoverageEligibilityRequest.supportingInformation.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.supportingInformation.sequence",
"requirements": "To provide a reference link.",
"min": 1,
"definition": "Sequence of the information element which serves to provide a link.",
"isModifier": false,
"short": "Information instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.supportingInformation.sequence",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.supportingInformation.sequence"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInformation.information",
"min": 1,
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"isModifier": false,
"short": "Additional Data or supporting information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.supportingInformation.information",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.supportingInformation.information"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInformation.appliesToAll",
"min": 0,
"definition": "The supporting materials are applicable for all detail intens, product/servce categories and specific billing codes.",
"isModifier": false,
"short": "Applies to all items",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.supportingInformation.appliesToAll",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.supportingInformation.appliesToAll"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.insurance",
"min": 0,
"definition": "Insurance policies which the patient has advised may be applicable for paying for health services.",
"isModifier": false,
"short": "Patient's Insurance or medical plan(s)",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.insurance",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.insurance"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.insurance.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "CoverageEligibilityRequest.insurance.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "CoverageEligibilityRequest.insurance.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.insurance.focal",
"requirements": "To identify which coverage is being adjudicated.",
"min": 0,
"definition": "A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"isModifier": false,
"short": "Is the focal Coverage",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.insurance.focal",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.insurance.focal"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance.coverage",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"definition": "Financial instrument by which payment information for health care.",
"isModifier": false,
"short": "Insurance or medical plan",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.insurance.coverage",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.insurance.coverage"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance.businessArrangement",
"min": 0,
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"isModifier": false,
"short": "Business agreement",
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.insurance.businessArrangement",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.insurance.businessArrangement"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item",
"min": 0,
"definition": "A list of service types or billable services for which bebefit details and/or an authorization prior to service delivery may be required by the payor.",
"isModifier": false,
"short": "Service types, codes and supporting information",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Details"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.item",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.item.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "CoverageEligibilityRequest.item.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "CoverageEligibilityRequest.item.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.item.supportingInformationSequence",
"min": 0,
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line.",
"isModifier": false,
"short": "Applicable exception and supporting information",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.item.supportingInformationSequence",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.supportingInformationSequence"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.category",
"min": 0,
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"isModifier": false,
"short": "Type of service",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral, medical, vision etc."
},
"max": "1",
"id": "CoverageEligibilityRequest.item.category",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.category"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.billcode",
"min": 0,
"definition": "A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"isModifier": false,
"short": "Billing Code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "CoverageEligibilityRequest.item.billcode",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.billcode"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.modifier",
"min": 0,
"definition": "Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "CoverageEligibilityRequest.item.modifier",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.modifier"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.provider",
"min": 0,
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"isModifier": false,
"short": "Perfoming practitioner",
"mapping": [ {
"map": "Request.requester",
"identity": "workflow"
}, {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.item.provider",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.provider"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.quantity",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.item.quantity",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.quantity"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.unitPrice",
"min": 0,
"definition": "The fee for an additional service or product or charge.",
"isModifier": false,
"short": "Fee, charge or cost per point",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "CoverageEligibilityRequest.item.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.unitPrice"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.facility",
"min": 0,
"definition": "Facility where the services were provided.",
"isModifier": false,
"short": "Servicing Facility",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.item.facility",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.facility"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.diagnosis",
"min": 0,
"definition": "List of patient diagnosis for which care is sought.",
"isModifier": false,
"short": "List of Diagnosis",
"mapping": [ {
"map": "Request.reasonReference",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.item.diagnosis",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.diagnosis"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.diagnosis.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.item.diagnosis.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.diagnosis.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "CoverageEligibilityRequest.item.diagnosis.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.diagnosis.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "CoverageEligibilityRequest.item.diagnosis.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 0,
"definition": "The diagnosis.",
"isModifier": false,
"short": "Patient's diagnosis",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/icd-10",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
} ],
"description": "ICD10 Diagnostic codes."
},
"max": "1",
"id": "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.detail",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 0,
"definition": "The plan/proposal/order describing the proposed service in detail.",
"isModifier": false,
"short": "Product or service details",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "CoverageEligibilityRequest.item.detail",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.detail"
},
"isSummary": false
} ]
},
"status": "draft",
"id": "9abe2399-44ce-4998-a07e-cca537db1ddd",
"kind": "resource",
"url": "http://hl7.org/fhir/StructureDefinition/CoverageEligibilityRequest",
"version": null,
"differential": {
"element": [ {
"id": "CoverageEligibilityRequest",
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest",
"short": "CoverageEligibilityRequest resource",
"mapping": [ {
"map": "Request",
"identity": "workflow"
} ],
"definition": "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."
}, {
"id": "CoverageEligibilityRequest.identifier",
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Business Identifier",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"definition": "The Response business identifier."
}, {
"path": "CoverageEligibilityRequest.status",
"requirements": "This element is labeled as a modifier because the status contains codes that mark the request as not currently valid.",
"min": 0,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Request.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "EligibilityRequestStatus"
} ],
"description": "A code specifying the state of the resource instance."
},
"max": "1",
"id": "CoverageEligibilityRequest.status",
"isModifierReason": "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.priority",
"min": 0,
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"short": "Desired processing priority",
"mapping": [ {
"map": "Request.priority",
"identity": "workflow"
}, {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/process-priority",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
} ],
"description": "The timeliness with which processing is required: STAT, normal, Deferred."
},
"max": "1",
"id": "CoverageEligibilityRequest.priority"
}, {
"path": "CoverageEligibilityRequest.purpose",
"min": 1,
"definition": "Specify whether requesting: prior authorization requirements for some service categories or billing codes; benefits for coverages specified or discovered; discovery and return of coverages for th patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.",
"short": "auth-requirements | benefits | discovery | validation",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "EligibilityRequestPurpose"
} ],
"description": "A code specifying the types of information being requested."
},
"max": "*",
"id": "CoverageEligibilityRequest.purpose",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.patient",
"min": 0,
"definition": "Patient Resource.",
"short": "The subject of the Products and Services",
"mapping": [ {
"map": "Request.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"max": "1",
"id": "CoverageEligibilityRequest.patient",
"comment": "1..1."
}, {
"id": "CoverageEligibilityRequest.serviced[x]",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.serviced[x]",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"short": "Estimated date or dates of Service",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"definition": "The date or dates when the enclosed suite of services were performed or completed."
}, {
"id": "CoverageEligibilityRequest.created",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.created",
"type": [ {
"code": "dateTime"
} ],
"short": "Creation date",
"mapping": [ {
"map": "Request.authoredOn",
"identity": "workflow"
}, {
"map": "FiveWs.recorded",
"identity": "w5"
} ],
"definition": "The date when this resource was created."
}, {
"id": "CoverageEligibilityRequest.enterer",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.enterer",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole" ]
} ],
"short": "Author",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
} ],
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization."
}, {
"id": "CoverageEligibilityRequest.provider",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.provider",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"short": "Responsible provider",
"mapping": [ {
"map": "Request.requester",
"identity": "workflow"
}, {
"map": "FiveWs.source",
"identity": "w5"
} ],
"definition": "The provider who is responsible for the services rendered to the patient."
}, {
"id": "CoverageEligibilityRequest.insurer",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.insurer",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"short": "Target",
"mapping": [ {
"map": "Request.performer",
"identity": "workflow"
}, {
"map": "FiveWs.who",
"identity": "w5"
} ],
"definition": "The Insurer who is target of the request."
}, {
"id": "CoverageEligibilityRequest.facility",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.facility",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"short": "Servicing Facility",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"definition": "Facility where the services were provided."
}, {
"path": "CoverageEligibilityRequest.supportingInformation",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Information"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.supportingInformation"
}, {
"id": "CoverageEligibilityRequest.supportingInformation.sequence",
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.supportingInformation.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link."
}, {
"id": "CoverageEligibilityRequest.supportingInformation.information",
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.supportingInformation.information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data."
}, {
"id": "CoverageEligibilityRequest.supportingInformation.appliesToAll",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.supportingInformation.appliesToAll",
"type": [ {
"code": "boolean"
} ],
"short": "Applies to all items",
"definition": "The supporting materials are applicable for all detail intens, product/servce categories and specific billing codes."
}, {
"id": "CoverageEligibilityRequest.insurance",
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.insurance",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Patient's Insurance or medical plan(s)",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"definition": "Insurance policies which the patient has advised may be applicable for paying for health services."
}, {
"id": "CoverageEligibilityRequest.insurance.focal",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.insurance.focal",
"type": [ {
"code": "boolean"
} ],
"short": "Is the focal Coverage",
"definition": "A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated."
}, {
"id": "CoverageEligibilityRequest.insurance.coverage",
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.insurance.coverage",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing."
}, {
"id": "CoverageEligibilityRequest.insurance.businessArrangement",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.insurance.businessArrangement",
"type": [ {
"code": "string"
} ],
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions."
}, {
"id": "CoverageEligibilityRequest.item",
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Service types, codes and supporting information",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Details"
} ],
"definition": "A list of service types or billable services for which bebefit details and/or an authorization prior to service delivery may be required by the payor."
}, {
"id": "CoverageEligibilityRequest.item.supportingInformationSequence",
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.supportingInformationSequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line."
}, {
"id": "CoverageEligibilityRequest.item.category",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service",
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral, medical, vision etc."
},
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc."
}, {
"id": "CoverageEligibilityRequest.item.billcode",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.billcode",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Billing Code",
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"definition": "A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)."
}, {
"id": "CoverageEligibilityRequest.item.modifier",
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.modifier",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Service/Product billing modifiers",
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"definition": "Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours."
}, {
"id": "CoverageEligibilityRequest.item.provider",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.provider",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole" ]
} ],
"short": "Perfoming practitioner",
"mapping": [ {
"map": "Request.requester",
"identity": "workflow"
}, {
"map": "FiveWs.source",
"identity": "w5"
} ],
"definition": "The practitioner who is responsible for the services rendered to the patient."
}, {
"id": "CoverageEligibilityRequest.item.quantity",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.quantity",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"short": "Count of products or services",
"definition": "The number of repetitions of a service or product."
}, {
"id": "CoverageEligibilityRequest.item.unitPrice",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.unitPrice",
"type": [ {
"code": "Money"
} ],
"short": "Fee, charge or cost per point",
"definition": "The fee for an additional service or product or charge."
}, {
"id": "CoverageEligibilityRequest.item.facility",
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.facility",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"short": "Servicing Facility",
"definition": "Facility where the services were provided."
}, {
"path": "CoverageEligibilityRequest.item.diagnosis",
"min": 0,
"definition": "List of patient diagnosis for which care is sought.",
"short": "List of Diagnosis",
"mapping": [ {
"map": "Request.reasonReference",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.item.diagnosis"
}, {
"path": "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 0,
"definition": "The diagnosis.",
"short": "Patient's diagnosis",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/icd-10",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
} ],
"description": "ICD10 Diagnostic codes."
},
"max": "1",
"id": "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]"
}, {
"id": "CoverageEligibilityRequest.item.detail",
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.detail",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"short": "Product or service details",
"definition": "The plan/proposal/order describing the proposed service in detail.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing."
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/fhir",
"system": "url"
} ]
}, {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/fm/index.cfm",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource"
}