Coverage Eligibility Request

$10 / year

The Coverage Eligibility Request provides patient and insurance coverage information to an insurer for them to respond, in the form of a Coverage Eligibility Response, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.

Complexity

The Coverage Eligibility Request makes a request of an insurer asking them to provide, in the form of a Coverage Eligibility Response, information regarding: (validation) whether the specified coverage(s) is valid and in force; (discovery) what coverages the insurer has for the specified patient; (benefits) the benefits provided under the coverage; whether benefits exist under the specified coverage(s) for specified classes of services and products; and (auth-requirements) whether pre-authorization is required, and if so what information may be required in that preauthorization, for the specified service classes or services.

Coverage Eligibility Request should be used when requesting whether the patient’s coverage is in force, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with coverage.

The Claim resource should be used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient’s insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

The Coverage resource contains the information typically found on the health insurance card for an individual user to identify the covered individual to the insurer and is referred to by the Coverage Eligibility Request.

The eClaim domain includes a number of related resources:

– Patient and insurance coverage information provided to an insurer for them to respond, in the form of Coverage Eligibility Response, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
– A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
– Provides the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services.

Fast Healthcare Interoperability Resources (FHIR) is a draft standard describing data formats and elements (known as “resources”) and an application programming interface (API) for exchanging electronic health records. The standard was created by the Health Level Seven International (HL7) health-care standards organization.

Its goal is to facilitate interoperation between legacy healthcare systems, to make it easy to provide healthcare information to healthcare providers and individuals on a wide variety of devices from computers to tablets to cell phones, and to allow third-party application developers to provide medical applications which can be easily integrated into existing systems.

FHIR provides an alternative to document-centric approaches by directly exposing discrete data elements as services. For example, basic elements of healthcare like patients, admissions, diagnostic reports and medications can each be retrieved and manipulated via their own resource URLs (Uniform Resource Locators). FHIR was supported at an American Medical Informatics Association meeting by many EHR (Electronic Health Record) vendors which value its open and extensible nature.

Date Created

2018-09-20

Last Modified

2019-11-01

Version

4.0.1

Update Frequency

Annual

Temporal Coverage

N/A

Spatial Coverage

United States

Source

John Snow Labs; Health Level Seven International;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

FHIR, HL7, Medical Terminology, Processes Data, Processes Information, Processes Documentation, Health Information Exchange, Electronic Health Records, FHIR Smart, Smart on FHIR

Other Titles

FHIR Coverage Eligibility Request Resource, Electronic Health Records Exchange Through FHIR

NameDescriptionTypeConstraints
Concept_NameName of the concept in the FHIR structurestringrequired : 1
Computer_Ready_NameA Computer-ready name (e.g. a token) that identifies the structure - suitable for code generation. Note that this name (and other names relevant for code generation, including element & slice names, codes etc) may collide with reserved words in the relevant target language, and code generators will need to handle this.string-
TypeThe type the structure describes.string-
Dollar_RefThe Dollar_Ref ($ref) string value contains a Uniform Resource Identifier (URI) which identifies the location of the JSON (JavaScript Object Notation) value being referenced.string-
DescriptionA free text natural language description of the structure and its usestring-
ItemsThe value of the keyword should be an object or an array of objects. If the keyword value is an object, then for the data array to be valid each item of the array should be valid according to the schema in this value.string-
RequiredThe value of the keyword should be an array of unique strings. The data object to be valid should contain all properties with names equal to the elements in the keyword value.string-
ConstThe value of this keyword can be anything. The data is valid if it is deeply equal to the value of the keyword.string-
Concept NameComputer Ready NameTypeDollar RefDescriptionItemsRequiredConst
CoverageEligibilityRequestresourceTypeThis is a CoverageEligibilityRequest resource
CoverageEligibilityRequestid#/definitions/idThe logical id of the resource as used in the URL for the resource. Once assigned this value never changes.
CoverageEligibilityRequestmeta#/definitions/MetaThe 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.
CoverageEligibilityRequestimplicitRules#/definitions/uriA 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.
CoverageEligibilityRequest_implicitRules#/definitions/ElementExtensions for implicitRules
CoverageEligibilityRequestlanguage#/definitions/codeThe base language in which the resource is written.
CoverageEligibilityRequest_language#/definitions/ElementExtensions for language
CoverageEligibilityRequesttext#/definitions/NarrativeA 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.
CoverageEligibilityRequestcontainedarrayThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently and nor can they have their own independent transaction scope.{'$ref': '#/definitions/ResourceList'}
CoverageEligibilityRequestextensionarrayMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension there is a set of requirements that SHALL be met as part of the definition of the extension.{'$ref': '#/definitions/Extension'}
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