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.
package_name: hl7.fhir.r5.examples
derivation: specialization
name: CoverageEligibilityRequest
type: CoverageEligibilityRequest
elements:
  patient:
    short: Intended recipient of products and services
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    isSummary: true
    index: 4
  insurance:
    short: Patient insurance information
    type: BackboneElement
    array: true
    index: 18
    elements:
      focal: {short: Applicable coverage, type: boolean, index: 19}
      coverage:
        short: Insurance information
        refers: ['http://hl7.org/fhir/StructureDefinition/Coverage']
        type: Reference
        index: 20
      businessArrangement: {type: string, short: Additional provider contract number, index: 21}
    required: [coverage]
  facility:
    short: Servicing facility
    refers: ['http://hl7.org/fhir/StructureDefinition/Location']
    type: Reference
    index: 13
  enterer:
    short: Author
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    index: 10
  supportingInfo:
    short: Supporting information
    type: BackboneElement
    array: true
    index: 14
    elements:
      sequence: {type: positiveInt, short: Information instance identifier, index: 15}
      information:
        short: Data to be provided
        refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
        type: Reference
        index: 16
      appliesToAll: {type: boolean, short: Applies to all items, index: 17}
    required: [sequence, information]
  purpose:
    min: 1
    short: auth-requirements | benefits | discovery | validation
    type: code
    array: true
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|4.5.0'}
    isSummary: true
    index: 3
  item:
    short: Item to be evaluated for eligibiity
    type: BackboneElement
    array: true
    index: 22
    elements:
      category:
        short: Benefit classification
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        index: 24
      facility:
        short: Servicing facility
        refers: ['http://hl7.org/fhir/StructureDefinition/Location', 'http://hl7.org/fhir/StructureDefinition/Organization']
        type: Reference
        index: 30
      diagnosis:
        short: Applicable diagnosis
        type: BackboneElement
        array: true
        index: 31
        elements:
          diagnosis:
            short: Nature of illness or problem
            choices: [diagnosisCodeableConcept, diagnosisReference]
            index: 33
          diagnosisCodeableConcept: {short: Nature of illness or problem, type: CodeableConcept, choiceOf: diagnosis, index: 34}
          diagnosisReference:
            short: Nature of illness or problem
            refers: ['http://hl7.org/fhir/StructureDefinition/Condition']
            type: Reference
            choiceOf: diagnosis
            index: 35
      modifier:
        short: Product or service billing modifiers
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        index: 26
      productOrService:
        short: Billing, service, product, or drug code
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        index: 25
      quantity: {type: Quantity, short: Count of products or services, index: 28}
      provider:
        short: Perfoming practitioner
        refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
        type: Reference
        index: 27
      supportingInfoSequence: {type: positiveInt, short: Applicable exception or supporting information, array: true, index: 23}
      unitPrice: {type: Money, short: 'Fee, charge or cost per item', index: 29}
      detail:
        short: Product or service details
        refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
        type: Reference
        array: true
        index: 36
  created: {short: Creation date, type: dateTime, isSummary: true, index: 9}
  serviced:
    short: Estimated date or dates of service
    choices: [servicedDate, servicedPeriod]
    index: 6
  insurer:
    short: Coverage issuer
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization']
    type: Reference
    isSummary: true
    index: 12
  priority:
    short: Desired processing priority
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    index: 2
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|4.5.0'}
    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
    index: 1
  servicedDate: {short: Estimated date or dates of service, type: date, choiceOf: serviced, index: 7}
  identifier: {short: Business Identifier for coverage eligiblity request, type: Identifier, array: true, index: 0}
  provider:
    short: Party responsible for the request
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    index: 11
  servicedPeriod: {short: Estimated date or dates of service, type: Period, choiceOf: serviced, index: 8}
package_version: 4.5.0
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/CoverageEligibilityRequest
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.5.0
required: [created, insurer, status, patient, purpose]