Generated Narrative: StructureDefinition eligibility-response Name Flags Card. Type Description & Constraints CoverageEligibilityResponse C 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource BV-00539: CoverageEligibilityResponse.status SHALL use the fixed value 'active'. ksa-purpose-unique-code: Purpose code values must be unique. BV-00310: CoverageEligibilityResponse.disposition SHALL have maximum length of 250 English characters and 125 Arabic characters. BV-00315: CoverageEligibilityResponse.preAuthRef SHALL have maximum length of 40 characters. BV-00503: CoverageEligibiltyResponse.extension.siteEligibility SHALL be provided when CoverageEligibiltyResponse.outcome='complete'. BV-00535: The CoverageEligibiltyResponse.extension.siteEligibility value SHALL not be 'eligible' if for every array entry of CoverageEligibiltyResponse.insurance the related CoverageEligibilityResponse.insurance.inforce value is 'false'. BV-00536: The CoverageEligibilityResponse.error SHALL be provided when CoverageEligibilityResponse.outcome= 'error'. BV-00559: The CoverageEligibiltyResponse.extension.siteEligibility value SHALL be 'eligible' if at least in one array entry of CoverageEligibiltyResponse.insurance the related CoverageEligibilityResponse.insurance.siteEligibility is 'eligible'. BV-00561: The CoverageEligibiltyResponse.extension.siteEligibility value SHALL not be 'eligible' if for every array entry of CoverageEligibiltyResponse.insurance the related CoverageEligibilityResponse.insurance.siteEligibility is not 'eligible'. id 1..1 id Logical id of this artifact Max Length:64 meta 1..1 Meta Metadata about the resource profile 1..* DP_canonical(StructureDefinition) Profiles this resource claims to conform to Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url extension:siteEligibility S 0..1 DP_CodeableConcept Site Eligibility URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility Binding: Site Eligibility (required) identifier 1..1 DP_Identifier_A Business Identifier for coverage eligiblity request type 0..1 CodeableConcept Description of identifier Binding: Identifier Type Codes (required) status 1..1 code active | cancelled | draft | entered-in-error Required Pattern: active purpose 1..* DP_code auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required) patient 1..1 DP_Reference_1or2a(Nphies Patient) Intended recipient of products and services identifier type 1..1 DP_CodeableConcept Description of identifier Binding: Patient Identifier Type (required) Slices for serviced[x] 1..1 date, Period Estimated date or dates of service Slice: Unordered, Open by type:$this serviced[x]:servicedDate S 0..1 DP_date Estimated date or dates of service serviced[x]:servicedPeriod S 0..1 DP_Period_2 Estimated date or dates of service created 1..1 DP_dateTime Response creation date request 1..1 DP_Reference_1or3a(Nphies CoverageEligibilityRequest) Eligibility request reference outcome 1..1 DP_code queued | complete | error | partial disposition S 0..1 string Disposition Message Max Length:250 insurer 1..1 DP_Reference_1or2a(Nphies Insurer Organization) Coverage issuer identifier type 1..1 DP_CodeableConcept Description of identifier Binding: Organization Identifier (required) insurance S 0..* BackboneElement Patient insurance information Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url extension:siteEligibility S 0..1 DP_CodeableConcept Site Eligibility URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility Binding: Site Eligibility (required) coverage 1..1 DP_Reference_1or2a(Nphies Coverage) Insurance information identifier type 1..1 DP_CodeableConcept Description of identifier Binding: Identifier Type Codes (required) inforce 1..1 boolean Coverage inforce indicator benefitPeriod S 0..1 DP_Period_2 When the benefits are applicable item SC 0..* BackboneElement Benefits and authorization details BV-00311: CoverageEligibilityResponse.insurance.item.name SHALL have maximum length of 100 English characters and 50 Arabic characters. BV-00312: CoverageEligibilityResponse.insurance.item.benefit.allowedString SHALL have maximum length of 60 characters. category S 0..1 DP_CodeableConcept Benefit classification Binding: Benefit Category (required) excluded S 0..1 boolean Excluded from the plan name S 0..1 string Short name for the benefit Max Length:100 description S 0..1 string Description of the benefit or services covered Max Length:250 network 1..1 DP_CodeableConcept In or out of network Binding: NetworkTypeCodes (required) unit 1..1 DP_CodeableConcept Individual or family Binding: UnitTypeCodes (required) term 1..1 DP_CodeableConcept Annual or lifetime Binding: BenefitTermCodes (required) benefit SC 0..* BackboneElement Benefit Summary BV-00313: CoverageEligibilityResponse.insurance.item.benefit.allowedString SHALL have maximum length of 60 characters. BV-00314: CoverageEligibilityResponse.insurance.item.benefit.usedString SHALL have maximum length of 60 characters. type 1..1 DP_CodeableConcept Benefit classification Binding: Benefit Type (required) Slices for allowed[x] 1..1 unsignedInt, string, Money Benefits allowed Slice: Unordered, Open by type:$this allowed[x]:allowedUnsignedInt S 0..1 DP_unsignedInt Benefits allowed allowed[x]:allowedString S 0..1 string Benefits allowed Max Length:60 allowed[x]:allowedMoney SC 0..1 DP_Money_SAR Benefits allowed BV-00084: CoverageEligibilityResponse.insurance.item.benefit.allowedMoney.currency SHALL be SAR Slices for used[x] S 0..1 unsignedInt, string, Money Benefits used Slice: Unordered, Open by type:$this used[x]:usedUnsignedInt S 0..1 DP_unsignedInt Benefits used used[x]:usedString S 0..1 string Benefits used Max Length:60 used[x]:usedMoney SC 0..1 DP_Money_SAR Benefits used BV-00085: CoverageEligibilityResponse.insurance.item.benefit.used.currency SHALL be SAR error S 0..* BackboneElement Processing errors Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url extension:expression S 0..1 string Error Expression URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression code 1..1 DP_CodeableConcept Error code detailing processing issues Binding: Adjudication Error Codes (required) Documentation for this format
Used by permission of HL7 International, all rights reserved Creative Commons License
Canadian Dental Association eclaims standard
This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
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.
A resource should have narrative for robust management
CoverageEligibilityResponse.status SHALL use the fixed value 'active'.
status.exists() implies status = 'active'
purpose.exists() implies purpose.isDistinct()
CoverageEligibilityResponse.disposition SHALL have maximum length of 250 English characters and 125 Arabic characters.
disposition.exists() implies disposition.length() <= 250
CoverageEligibilityResponse.preAuthRef SHALL have maximum length of 40 characters.
preAuthRef.exists() implies preAuthRef.length() <= 40
CoverageEligibiltyResponse.extension.siteEligibility SHALL be provided when CoverageEligibiltyResponse.outcome='complete'.
outcome.exists() implies (outcome = 'complete' implies extension.where(url = 'http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility').exists())
The CoverageEligibiltyResponse.extension.siteEligibility value SHALL not be 'eligible' if for every array entry of CoverageEligibiltyResponse.insurance the related CoverageEligibilityResponse.insurance.inforce value is 'false'.
iif( (insurance.where(inforce = true).count() = 0) and (extension.where(url = 'http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility').count()=1), iif((extension.where(url = 'http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility').value.ofType(CodeableConcept).coding.first().code='eligible') ,false,true), true)
The CoverageEligibilityResponse.error SHALL be provided when CoverageEligibilityResponse.outcome= 'error'.
outcome.exists() implies (outcome = 'error' implies error.exists())
The CoverageEligibiltyResponse.extension.siteEligibility value SHALL be 'eligible' if at least in one array entry of CoverageEligibiltyResponse.insurance the related CoverageEligibilityResponse.insurance.siteEligibility is 'eligible'.
iif( insurance.extension.exists(), iif( (insurance.extension.where(url='http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility').value.ofType(CodeableConcept).coding.where(code='eligible').count() > 0), iif( extension.exists(), (extension.where(url='http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility').value.ofType(CodeableConcept).coding.where(code='eligible').count() > 0), true), false), true)
The CoverageEligibiltyResponse.extension.siteEligibility value SHALL not be 'eligible' if for every array entry of CoverageEligibiltyResponse.insurance the related CoverageEligibilityResponse.insurance.siteEligibility is not 'eligible'.
iif( (extension.where(url='http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility').count() = 1), iif(extension.where(url='http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility').first().value.ofType(CodeableConcept).coding.first().code='eligible', iif(insurance.extension.exists(),insurance.extension.where(url='http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-siteEligibility').select(value.ofType(CodeableConcept).coding.select(code='eligible').count()>0),false),false), true)
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
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.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
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 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.
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a [read](http://hl7.org/fhir/R4/http.html#read) interaction.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
A set of rules under which this content was created
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.
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 it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
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).
Text summary of the resource, for human interpretation
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.
Contained resources do not have 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.
These 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.
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.
Code to indicate whether the patient is eligible or not eligible and why.
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
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 manageable, 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Business Identifier for coverage eligiblity request
A unique identifier assigned to this coverage eligiblity request.
Allows coverage eligibility requests to be distinguished and referenced.
usual | official | temp | secondary | old (If known)
Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Identifies the purpose for this identifier, if known .
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Allows users to make use of identifiers when the identifier system is not known.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Identifier.system is always case sensitive.
There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](http://hl7.org/fhir/R4/extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
Time period when id is/was valid for use
Time period during which identifier is/was valid for use.
Role.effectiveTime or implied by context
Organization that issued id (may be just text)
Organization that issued/manages the identifier.
The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
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'.
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
A code specifying the state of the resource instance.
auth-requirements | benefits | discovery | validation
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.
To indicate the processing actions requested.
Intended recipient of products and services
The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.
Required to provide context and coverage validation.
Literal reference, Relative, internal or absolute URL
A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Type the reference refers to (e.g. "Patient")
The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
Logical reference, when literal reference is not known
An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Plain text narrative that identifies the resource in addition to the resource reference.
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
The date or dates when the enclosed suite of services were performed or completed.
Required to provide time context for the request.
Need to record a timestamp for use by both the recipient and the issuer.
The provider which is responsible for the request.
Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
Reference to the original request resource.
Needed to allow the response to be linked to the request.
The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
To advise the requestor of an overall processing outcome.
A human readable description of the status of the adjudication.
The Insurer who issued the coverage in question and is the author of the response.
Financial instruments for reimbursement for the health care products and services.
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.
There must be at least one coverage for which eligibility is requested.
Extensions that cannot be ignored even if unrecognized
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 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
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.
Required to allow the adjudicator to locate the correct policy and history within their information system.
Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.
Needed to convey the answer to the eligibility validation request.
The term of the benefits documented in this response.
Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.
Benefits and optionally current balances, and authorization details by category or service.
SHALL contain a category or a billcode but not both.
category.exists() xor productOrService.exists()
exists(f:category) or exists(f:productOrService)
CoverageEligibilityResponse.insurance.item.name SHALL have maximum length of 100 English characters and 50 Arabic characters.
name.exists() implies name.length() <= 100
CoverageEligibilityResponse.insurance.item.benefit.allowedString SHALL have maximum length of 60 characters.
name.exists() implies name.length() <= 60
Code to identify the general type of benefits under which products and services are provided.
Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Needed to convey the category of service or product for which eligibility is sought.
This contains the product, service, drug or other billing code for the item.
Code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI).
Needed to convey the actual service or product for which eligibility is sought.
Item typification or modifiers codes to convey additional context for the product or service.
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.
To support provision of the item or to charge an elevated fee.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
The practitioner who is eligible for the provision of the product or service.
True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
Needed to identify items that are specifically excluded from the coverage.
Required to align with other plan names.
Description of the benefit or services covered
A richer description of the benefit or services covered.
For example 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
Needed as in or out of network providers are treated differently under the coverage.
Indicates if the benefits apply to an individual or to the family.
Needed for the understanding of the benefits.
The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
allowed.ofType(string).exists() implies allowed.ofType(string).length() <= 60
CoverageEligibilityResponse.insurance.item.benefit.usedString SHALL have maximum length of 60 characters.
used.ofType(string).exists() implies used.ofType(string).length() <= 60
Classification of benefit being provided.
For example: deductible, visits, benefit amount.
Needed to convey the nature of the benefit.
The quantity of the benefit which is permitted under the coverage.
Needed to convey the benefits offered under the coverage.
CoverageEligibilityResponse.insurance.item.benefit.allowedMoney.currency SHALL be SAR
currency.exists() implies currency ='SAR'
The quantity of the benefit which have been consumed to date.
Needed to convey the benefits consumed to date.
CoverageEligibilityResponse.insurance.item.benefit.used.currency SHALL be SAR
A boolean flag indicating whether a preauthorization is required prior to actual service delivery.
Needed to convey that preauthorization is required.
Codes or comments regarding information or actions associated with the preauthorization.
Needed to inform the provider of collateral materials or actions needed for preauthorization.
Type of supporting information to provide with a preauthorization.
A web location for obtaining requirements or descriptive information regarding the preauthorization.
Needed to enable insurers to advise providers of informative information.
A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.
To provide any preauthorization reference for provider use.
A code for the form to be used for printing the content.
May be needed to identify specific jurisdictional forms.
Needed to specify the specific form used for producing output for this response.
Errors encountered during the processing of the request.
Need to communicate processing issues to the requestor.
Expression for error location as part of error reporting to indicate the location of error.
An error code,from a specified code system, which details why the eligibility check could not be performed.