{
"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.r6.core",
"date": "2024-08-12T16:52:12+08:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2024-08-12T16:52:12.437+08:00"
},
"publisher": "HL7 International / Financial Management",
"fhirVersion": "6.0.0-ballot2",
"jurisdiction": [ {
"coding": [ {
"code": "001",
"system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
"display": "World"
} ]
} ],
"name": "CoverageEligibilityRequest",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern Mapping",
"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": "false",
"resourceType": "StructureDefinition",
"title": null,
"package_version": "6.0.0-ballot2",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString": "Financial.Support"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode": "trial-use"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 4
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
"valueCode": "patient"
} ],
"snapshot": {
"element": [ {
"constraint": [ {
"key": "dom-2",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.contained.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",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()"
}, {
"key": "dom-4",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-5",
"human": "If a resource is contained in another resource, it SHALL NOT have a security label",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.meta.security.empty()"
}, {
"key": "dom-6",
"human": "A resource should have narrative for robust management",
"source": "http://hl7.org/fhir/StructureDefinition/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 human 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()"
} ],
"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"
}, {
"map": "financial.support",
"identity": "w5"
} ],
"mustSupport": false,
"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": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "id"
} ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.id",
"comment": "Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"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"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"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"
} ],
"mustSupport": false,
"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 its 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 its meaning or interpretation",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"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"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/all-languages|6.0.0-ballot2",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"additional": [ {
"purpose": "starter",
"valueSet": "http://hl7.org/fhir/ValueSet/languages"
} ],
"description": "IETF language tag for 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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"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"
} ],
"mustSupport": false,
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "CoverageEligibilityRequest.text",
"condition": [ "dom-6" ],
"comment": "Contained resources do not have a 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, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.",
"isModifier": false,
"short": "Contained, inline Resources",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"mustSupport": false,
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "CoverageEligibilityRequest.contained",
"condition": [ "dom-2", "dom-4", "dom-3", "dom-5" ],
"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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"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 managable, 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"
} ],
"mustSupport": false,
"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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, 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"
} ],
"mustSupport": false,
"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": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.identifier",
"requirements": "Allows coverage eligibility requests to be distinguished and referenced.",
"min": 0,
"definition": "A unique identifier assigned to this coverage eligiblity request.",
"isModifier": false,
"short": "Business Identifier for coverage eligiblity request",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest.identifier",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.identifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.status",
"requirements": "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.",
"min": 1,
"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"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status|6.0.0-ballot2",
"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",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"base": {
"max": "1",
"min": 1,
"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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.priority",
"requirements": "Needed to advise the prossesor on the urgency of the request.",
"min": 0,
"definition": "When the requestor expects the processor to complete processing.",
"isModifier": false,
"short": "Desired processing priority",
"mapping": [ {
"map": "Request.priority",
"identity": "workflow"
}, {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.purpose",
"requirements": "To indicate the processing actions requested.",
"min": 1,
"definition": "Code to 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 the 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"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|6.0.0-ballot2",
"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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.patient",
"requirements": "Required to provide context and coverage validation.",
"min": 1,
"definition": "The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.",
"isModifier": false,
"short": "Intended recipient of products and services",
"mapping": [ {
"map": "Request.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.patient",
"comment": "1..1.",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.patient"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.event",
"min": 0,
"definition": "Information code for an event with a corresponding date or period.",
"isModifier": false,
"short": "Event information",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest.event",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.event"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.event.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": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.event.id",
"condition": [ "ele-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.event.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 managable, 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.event.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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.event.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, 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 even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "CoverageEligibilityRequest.event.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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.event.type",
"min": 1,
"definition": "A coded event such as when a service is expected or a card printed.",
"isModifier": false,
"short": "Specific event",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/datestype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DatesType"
} ]
},
"max": "1",
"id": "CoverageEligibilityRequest.event.type",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.event.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.event.when[x]",
"min": 1,
"definition": "A date or period in the past or future indicating when the event occurred or is expectd to occur.",
"isModifier": false,
"short": "Occurance date or period",
"type": [ {
"code": "dateTime"
}, {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.event.when[x]",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.event.when[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.serviced[x]",
"requirements": "Required to provide time context for the request.",
"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"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.serviced[x]",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.serviced[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.created",
"requirements": "Need to record a timestamp for use by both the recipient and the issuer.",
"min": 1,
"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"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.created",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.created"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.enterer",
"requirements": "Some jurisdictions require the contact information for personnel completing eligibility requests.",
"min": 0,
"definition": "Person who created the request.",
"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" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.enterer",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.enterer"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.provider",
"requirements": "Needed to identify the requestor.",
"min": 0,
"definition": "The provider which is responsible for the request.",
"isModifier": false,
"short": "Party responsible for the request",
"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" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.provider",
"comment": "Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.provider"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.insurer",
"requirements": "Need to identify the recipient.",
"min": 1,
"definition": "The Insurer who issued the coverage in question and is the recipient of the request.",
"isModifier": false,
"short": "Coverage issuer",
"mapping": [ {
"map": "Request.performer",
"identity": "workflow"
}, {
"map": "FiveWs.who",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.insurer",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.insurer"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.facility",
"requirements": "Insurance adjudication can be dependant on where services were delivered.",
"min": 0,
"definition": "Facility where the services are intended to be provided.",
"isModifier": false,
"short": "Servicing facility",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"mustSupport": false,
"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",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.supportingInfo",
"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.",
"isModifier": false,
"short": "Supporting information",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.supportingInfo",
"comment": "Often there are multiple jurisdiction specific valuesets which are required.",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.supportingInfo"
},
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInfo.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": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.supportingInfo.id",
"condition": [ "ele-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.supportingInfo.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 managable, 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.supportingInfo.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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.supportingInfo.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, 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 even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "CoverageEligibilityRequest.supportingInfo.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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.supportingInfo.sequence",
"requirements": "Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify supporting information entries.",
"isModifier": false,
"short": "Information instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.supportingInfo.sequence",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.supportingInfo.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.supportingInfo.information",
"requirements": "To convey the data content to be provided when the information is more than a simple code or period.",
"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": "Data to be provided",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.supportingInfo.information",
"comment": "Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.supportingInfo.information"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"requirements": "Needed to convey that the information is universal to the request.",
"min": 0,
"definition": "The supporting materials are applicable for all detail items, product/servce categories and specific billing codes.",
"isModifier": false,
"short": "Applies to all items",
"type": [ {
"code": "boolean"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.supportingInfo.appliesToAll"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.insurance",
"requirements": "There must be at least one coverage for which eligibility is requested.",
"min": 0,
"definition": "Financial instruments for reimbursement for the health care products and services.",
"isModifier": false,
"short": "Patient insurance information",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.insurance",
"comment": "All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.",
"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": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.insurance.id",
"condition": [ "ele-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"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 managable, 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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.insurance.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, 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 even 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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.insurance.focal",
"requirements": "To identify which coverage in the list is being used to evaluate this request.",
"min": 0,
"definition": "A flag to indicate that this Coverage is to be used for evaluation of this request when set to true.",
"isModifier": false,
"short": "Applicable coverage",
"type": [ {
"code": "boolean"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.insurance.focal",
"comment": "A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for evaluating this request. Other requests would be created to request evaluation against the other listed policies.",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.insurance.focal"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.insurance.coverage",
"requirements": "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min": 1,
"definition": "Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.",
"isModifier": false,
"short": "Insurance information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.insurance.coverage",
"base": {
"max": "1",
"min": 1,
"path": "CoverageEligibilityRequest.insurance.coverage"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.insurance.businessArrangement",
"requirements": "Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.",
"min": 0,
"definition": "A business agreement number established between the provider and the insurer for special business processing purposes.",
"isModifier": false,
"short": "Additional provider contract number",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"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",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item",
"requirements": "The items to be processed for the request.",
"min": 0,
"definition": "Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor.",
"isModifier": false,
"short": "Item to be evaluated for eligibiity",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"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": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.item.id",
"condition": [ "ele-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"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 managable, 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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, 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 even 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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.supportingInfoSequence",
"requirements": "Needed to support or inform the consideration for eligibility.",
"min": 0,
"definition": "Exceptions, special conditions and supporting information applicable for this service or product line.",
"isModifier": false,
"short": "Applicable exception or supporting information",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest.item.supportingInfoSequence",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.supportingInfoSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.category",
"requirements": "Needed to convey the category of service or product for which eligibility is sought.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"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",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.category"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.productOrService",
"requirements": "Needed to convey the actual service or product for which eligibility is sought.",
"min": 0,
"definition": "This contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"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.productOrService",
"comment": "Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.modifier",
"requirements": "To support provision of the item or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Product or service billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"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",
"comment": "For example in 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.",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.provider",
"requirements": "Needed to support the evaluation of the eligibility.",
"min": 0,
"definition": "The practitioner who is responsible for the product or service to be 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" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.item.provider",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.provider"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"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" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.item.quantity",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.unitPrice",
"requirements": "Needed to support the evaluation of the eligibility.",
"min": 0,
"definition": "The amount charged to the patient by the provider for a single unit.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.item.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "CoverageEligibilityRequest.item.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.facility",
"requirements": "Needed to support the evaluation of the eligibility.",
"min": 0,
"definition": "Facility where the services will be provided.",
"isModifier": false,
"short": "Servicing facility",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"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",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.diagnosis",
"requirements": "Needed to support the evaluation of the eligibility.",
"min": 0,
"definition": "Patient diagnosis for which care is sought.",
"isModifier": false,
"short": "Applicable diagnosis",
"mapping": [ {
"map": "Request.reasonReference",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"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": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "CoverageEligibilityRequest.item.diagnosis.id",
"condition": [ "ele-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"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 managable, 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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.diagnosis.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, 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 even 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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"requirements": "Provides health context for the evaluation of the products and/or services.",
"min": 0,
"definition": "The nature of illness or problem in a coded form or as a reference to an external defined Condition.",
"isModifier": false,
"short": "Nature of illness or problem",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ]
} ],
"mustSupport": false,
"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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "CoverageEligibilityRequest.item.detail",
"requirements": "Needed to provide complex service proposal such as a Device or a plan.",
"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" ]
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest.item.detail",
"base": {
"max": "*",
"min": 0,
"path": "CoverageEligibilityRequest.item.detail"
},
"isSummary": false
} ]
},
"status": "draft",
"id": "a422ef78-0bb5-4956-88ec-a52edcae450d",
"kind": "resource",
"url": "http://hl7.org/fhir/StructureDefinition/CoverageEligibilityRequest",
"version": "6.0.0-ballot2",
"differential": {
"element": [ {
"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": "Request",
"identity": "workflow"
}, {
"map": "financial.support",
"identity": "w5"
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest"
}, {
"path": "CoverageEligibilityRequest.identifier",
"requirements": "Allows coverage eligibility requests to be distinguished and referenced.",
"min": 0,
"definition": "A unique identifier assigned to this coverage eligiblity request.",
"isModifier": false,
"short": "Business Identifier for coverage eligiblity request",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest.identifier",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.status",
"requirements": "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.",
"min": 1,
"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"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status|6.0.0-ballot2",
"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",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"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",
"requirements": "Needed to advise the prossesor on the urgency of the request.",
"min": 0,
"definition": "When the requestor expects the processor to complete processing.",
"isModifier": false,
"short": "Desired processing priority",
"mapping": [ {
"map": "Request.priority",
"identity": "workflow"
}, {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"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",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.purpose",
"requirements": "To indicate the processing actions requested.",
"min": 1,
"definition": "Code to 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 the 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"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|6.0.0-ballot2",
"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",
"requirements": "Required to provide context and coverage validation.",
"min": 1,
"definition": "The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.",
"isModifier": false,
"short": "Intended recipient of products and services",
"mapping": [ {
"map": "Request.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.patient",
"comment": "1..1.",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.event",
"min": 0,
"definition": "Information code for an event with a corresponding date or period.",
"isModifier": false,
"short": "Event information",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest.event",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.event.type",
"min": 1,
"definition": "A coded event such as when a service is expected or a card printed.",
"isModifier": false,
"short": "Specific event",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/datestype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DatesType"
} ]
},
"max": "1",
"id": "CoverageEligibilityRequest.event.type",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.event.when[x]",
"min": 1,
"definition": "A date or period in the past or future indicating when the event occurred or is expectd to occur.",
"isModifier": false,
"short": "Occurance date or period",
"type": [ {
"code": "dateTime"
}, {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.event.when[x]",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.serviced[x]",
"requirements": "Required to provide time context for the request.",
"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"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.serviced[x]",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.created",
"requirements": "Need to record a timestamp for use by both the recipient and the issuer.",
"min": 1,
"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"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.created",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.enterer",
"requirements": "Some jurisdictions require the contact information for personnel completing eligibility requests.",
"min": 0,
"definition": "Person who created the request.",
"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" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.enterer",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.provider",
"requirements": "Needed to identify the requestor.",
"min": 0,
"definition": "The provider which is responsible for the request.",
"isModifier": false,
"short": "Party responsible for the request",
"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" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.provider",
"comment": "Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurer",
"requirements": "Need to identify the recipient.",
"min": 1,
"definition": "The Insurer who issued the coverage in question and is the recipient of the request.",
"isModifier": false,
"short": "Coverage issuer",
"mapping": [ {
"map": "Request.performer",
"identity": "workflow"
}, {
"map": "FiveWs.who",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.insurer",
"isSummary": true
}, {
"path": "CoverageEligibilityRequest.facility",
"requirements": "Insurance adjudication can be dependant on where services were delivered.",
"min": 0,
"definition": "Facility where the services are intended to be provided.",
"isModifier": false,
"short": "Servicing facility",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.facility",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInfo",
"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.",
"isModifier": false,
"short": "Supporting information",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.supportingInfo",
"comment": "Often there are multiple jurisdiction specific valuesets which are required.",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInfo.sequence",
"requirements": "Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify supporting information entries.",
"isModifier": false,
"short": "Information instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.supportingInfo.sequence",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInfo.information",
"requirements": "To convey the data content to be provided when the information is more than a simple code or period.",
"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": "Data to be provided",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.supportingInfo.information",
"comment": "Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"requirements": "Needed to convey that the information is universal to the request.",
"min": 0,
"definition": "The supporting materials are applicable for all detail items, product/servce categories and specific billing codes.",
"isModifier": false,
"short": "Applies to all items",
"type": [ {
"code": "boolean"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.supportingInfo.appliesToAll",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance",
"requirements": "There must be at least one coverage for which eligibility is requested.",
"min": 0,
"definition": "Financial instruments for reimbursement for the health care products and services.",
"isModifier": false,
"short": "Patient insurance information",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.insurance",
"comment": "All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance.focal",
"requirements": "To identify which coverage in the list is being used to evaluate this request.",
"min": 0,
"definition": "A flag to indicate that this Coverage is to be used for evaluation of this request when set to true.",
"isModifier": false,
"short": "Applicable coverage",
"type": [ {
"code": "boolean"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.insurance.focal",
"comment": "A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for evaluating this request. Other requests would be created to request evaluation against the other listed policies.",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance.coverage",
"requirements": "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min": 1,
"definition": "Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.",
"isModifier": false,
"short": "Insurance information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.insurance.coverage",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.insurance.businessArrangement",
"requirements": "Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.",
"min": 0,
"definition": "A business agreement number established between the provider and the insurer for special business processing purposes.",
"isModifier": false,
"short": "Additional provider contract number",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.insurance.businessArrangement",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item",
"requirements": "The items to be processed for the request.",
"min": 0,
"definition": "Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor.",
"isModifier": false,
"short": "Item to be evaluated for eligibiity",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Details"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.item",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.supportingInfoSequence",
"requirements": "Needed to support or inform the consideration for eligibility.",
"min": 0,
"definition": "Exceptions, special conditions and supporting information applicable for this service or product line.",
"isModifier": false,
"short": "Applicable exception or supporting information",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest.item.supportingInfoSequence",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.category",
"requirements": "Needed to convey the category of service or product for which eligibility is sought.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"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",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.productOrService",
"requirements": "Needed to convey the actual service or product for which eligibility is sought.",
"min": 0,
"definition": "This contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"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.productOrService",
"comment": "Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.modifier",
"requirements": "To support provision of the item or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Product or service billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"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",
"comment": "For example in 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.",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.provider",
"requirements": "Needed to support the evaluation of the eligibility.",
"min": 0,
"definition": "The practitioner who is responsible for the product or service to be 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" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.item.provider",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"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" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.item.quantity",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.unitPrice",
"requirements": "Needed to support the evaluation of the eligibility.",
"min": 0,
"definition": "The amount charged to the patient by the provider for a single unit.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.item.unitPrice",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.facility",
"requirements": "Needed to support the evaluation of the eligibility.",
"min": 0,
"definition": "Facility where the services will be provided.",
"isModifier": false,
"short": "Servicing facility",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"id": "CoverageEligibilityRequest.item.facility",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.diagnosis",
"requirements": "Needed to support the evaluation of the eligibility.",
"min": 0,
"definition": "Patient diagnosis for which care is sought.",
"isModifier": false,
"short": "Applicable diagnosis",
"mapping": [ {
"map": "Request.reasonReference",
"identity": "v2"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"id": "CoverageEligibilityRequest.item.diagnosis",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.diagnosis.diagnosis[x]",
"requirements": "Provides health context for the evaluation of the products and/or services.",
"min": 0,
"definition": "The nature of illness or problem in a coded form or as a reference to an external defined Condition.",
"isModifier": false,
"short": "Nature of illness or problem",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ]
} ],
"mustSupport": false,
"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]",
"isSummary": false
}, {
"path": "CoverageEligibilityRequest.item.detail",
"requirements": "Needed to provide complex service proposal such as a Device or a plan.",
"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" ]
} ],
"mustSupport": false,
"max": "*",
"id": "CoverageEligibilityRequest.item.detail",
"isSummary": false
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/fiwg",
"system": "url"
} ]
}, {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/fm",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource"
}