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.