description: The CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
package_name: hl7.fhir.r5.examples
derivation: specialization
name: CoverageEligibilityRequest
type: CoverageEligibilityRequest
elements:
  patient:
    isModifier: false
    short: Intended recipient of products and services
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    mustSupport: false
    isSummary: true
    index: 4
  insurance:
    isModifier: false
    short: Patient insurance information
    index: 24
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      focal: {isModifier: false, short: Applicable coverage, type: boolean, mustSupport: false, isSummary: false, index: 25}
      coverage:
        isModifier: false
        short: Insurance information
        refers: ['http://hl7.org/fhir/StructureDefinition/Coverage']
        type: Reference
        mustSupport: false
        isSummary: false
        index: 26
      businessArrangement: {isModifier: false, short: Additional provider contract number, type: string, mustSupport: false, isSummary: false, index: 27}
    required: [coverage]
    isSummary: false
  facility:
    isModifier: false
    short: Servicing facility
    refers: ['http://hl7.org/fhir/StructureDefinition/Location']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 19
  enterer:
    isModifier: false
    short: Author
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 16
  supportingInfo:
    isModifier: false
    short: Supporting information
    index: 20
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      sequence: {isModifier: false, short: Information instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 21}
      information:
        isModifier: false
        short: Data to be provided
        refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
        type: Reference
        mustSupport: false
        isSummary: false
        index: 22
      appliesToAll: {isModifier: false, short: Applies to all items, type: boolean, mustSupport: false, isSummary: false, index: 23}
    required: [sequence, information]
    isSummary: false
  purpose:
    min: 1
    isModifier: false
    short: auth-requirements | benefits | discovery | validation
    index: 3
    type: code
    mustSupport: false
    array: true
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/eligibilityrequest-purpose|5.0.0-draft-final'}
    isSummary: true
  item:
    isModifier: false
    short: Item to be evaluated for eligibiity
    type: BackboneElement
    mustSupport: false
    array: true
    isSummary: false
    index: 28
    elements:
      category:
        isModifier: false
        short: Benefit classification
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        isSummary: false
        index: 30
      facility:
        isModifier: false
        short: Servicing facility
        refers: ['http://hl7.org/fhir/StructureDefinition/Location', 'http://hl7.org/fhir/StructureDefinition/Organization']
        type: Reference
        mustSupport: false
        isSummary: false
        index: 36
      diagnosis:
        isModifier: false
        short: Applicable diagnosis
        type: BackboneElement
        mustSupport: false
        array: true
        isSummary: false
        index: 37
        elements:
          diagnosis:
            isModifier: false
            short: Nature of illness or problem
            mustSupport: false
            choices: [diagnosisCodeableConcept, diagnosisReference]
            isSummary: false
            index: 39
          diagnosisCodeableConcept: {isModifier: false, short: Nature of illness or problem, type: CodeableConcept, mustSupport: false, choiceOf: diagnosis, isSummary: false, index: 40}
          diagnosisReference:
            isModifier: false
            short: Nature of illness or problem
            refers: ['http://hl7.org/fhir/StructureDefinition/Condition']
            type: Reference
            mustSupport: false
            choiceOf: diagnosis
            isSummary: false
            index: 41
      modifier:
        isModifier: false
        short: Product or service billing modifiers
        type: CodeableConcept
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        isSummary: false
        index: 32
      productOrService:
        isModifier: false
        short: Billing, service, product, or drug code
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 31
      quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 34}
      provider:
        isModifier: false
        short: Perfoming practitioner
        refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
        type: Reference
        mustSupport: false
        isSummary: false
        index: 33
      supportingInfoSequence: {isModifier: false, short: Applicable exception or supporting information, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 29}
      unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 35}
      detail:
        isModifier: false
        short: Product or service details
        refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
        type: Reference
        mustSupport: false
        array: true
        isSummary: false
        index: 42
  created: {isModifier: false, short: Creation date, type: dateTime, mustSupport: false, isSummary: true, index: 15}
  serviced:
    isModifier: false
    short: Estimated date or dates of service
    mustSupport: false
    choices: [servicedDate, servicedPeriod]
    isSummary: false
    index: 12
  event:
    isModifier: false
    short: Event information
    index: 5
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      type:
        isModifier: false
        short: Specific event
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/datestype'}
        isSummary: false
        index: 6
      when:
        isModifier: false
        short: Occurance date or period
        mustSupport: false
        choices: [whenDateTime, whenPeriod]
        isSummary: false
        index: 8
      whenDateTime: {isModifier: false, short: Occurance date or period, type: dateTime, mustSupport: false, choiceOf: when, isSummary: false, index: 9}
      whenPeriod: {isModifier: false, short: Occurance date or period, type: Period, mustSupport: false, choiceOf: when, isSummary: false, index: 10}
    required: [when, type, whenDateTime, whenPeriod]
    isSummary: false
  insurer:
    isModifier: false
    short: Coverage issuer
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization']
    type: Reference
    mustSupport: false
    isSummary: true
    index: 18
  priority:
    isModifier: false
    short: Desired processing priority
    type: CodeableConcept
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    isSummary: false
    index: 2
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    index: 1
    type: code
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|5.0.0-draft-final'}
    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
  servicedDate: {isModifier: false, short: Estimated date or dates of service, type: date, mustSupport: false, choiceOf: serviced, isSummary: false, index: 13}
  identifier: {isModifier: false, short: Business Identifier for coverage eligiblity request, type: Identifier, mustSupport: false, array: true, isSummary: false, index: 0}
  provider:
    isModifier: false
    short: Party responsible for the request
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 17
  servicedPeriod: {isModifier: false, short: Estimated date or dates of service, type: Period, mustSupport: false, choiceOf: serviced, isSummary: false, index: 14}
package_version: 5.0.0-draft-final
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/CoverageEligibilityRequest
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 5.0.0-draft-final
required: [created, insurer, status, patient, purpose]