FHIR Implementation Guide for HCX
0.0.1 - CI Build
FHIR Implementation Guide for HCX
0.0.1 - CI Build
FHIR Implementation Guide for HCX - Local Development build (v0.0.1). See the Directory of published versions
| Defining URL: | http://hl7.org/fhir/StructureDefinition/HCXCoverageEligibilityRequest |
| Version: | 0.0.1 |
| Name: | CoverageEligibilityRequest |
| Status: | Draft as of 2019-11-01T09:29:23+11:00 (Standards Status: Trial Use) |
| 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. |
| Publisher: | HL7 International - HCX |
| Committee: | Financial Management |
| Maturity: | 2 |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/StructureDefinition/HCXCoverageEligibilityRequest
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CoverageEligibilityRequest
This structure is derived from CoverageEligibilityRequest
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |
  identifier | 1..1 | Identifier | Business Identifier for coverage eligiblity request | |
| priority | 1..1 | CodeableConcept | Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred. | |
 enterer | 1..1 | Reference(Practitioner | PractitionerRole) | Author | |
| provider | 1..1 | Reference(Practitioner | Organization) | Party responsible for the request | |
  insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer Binding: https://swasth-digital-health-foundation.github.io/standards/output/ValueSet-insurance-company-owners.html (example): Insurance Company Owners |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Additional content defined by implementations | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | 1..1 | Identifier | Business Identifier for coverage eligiblity request | |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| priority | 1..1 | CodeableConcept | Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred. | |
| purpose | Σ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested. |
| patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services |
  serviced[x] | 0..1 | Estimated date or dates of service | ||
 servicedDate | date | |||
| servicedPeriod | Period | |||
| created | Σ | 1..1 | dateTime | Creation date |
| enterer | 1..1 | Reference(Practitioner | PractitionerRole) | Author | |
| provider | 1..1 | Reference(Practitioner | Organization) | Party responsible for the request | |
| insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer |
| facility | 0..1 | Reference(Location) | Servicing facility | |
| supportingInfo | 0..* | BackboneElement | Supporting information | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| information | 1..1 | Reference(Resource) | Data to be provided | |
| appliesToAll | 0..1 | boolean | Applies to all items | |
| insurance | 0..* | BackboneElement | Patient insurance information | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | 0..1 | boolean | Applicable coverage | |
| coverage | 1..1 | Reference(Coverage) | Insurance information | |
| businessArrangement | 0..1 | string | Additional provider contract number | |
 item | 0..* | BackboneElement | Item to be evaluated for eligibiity | |
 extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| supportingInfoSequence | 0..* | positiveInt | Applicable exception or supporting information | |
| category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc. | |
| productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
| provider | 0..1 | Reference(Practitioner | PractitionerRole) | Perfoming practitioner | |
| quantity | 0..1 | SimpleQuantity | Count of products or services | |
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |
| facility | 0..1 | Reference(Location | Organization) | Servicing facility | |
| diagnosis | 0..* | BackboneElement | Applicable diagnosis | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| diagnosis[x] | 0..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||
| diagnosisCodeableConcept | CodeableConcept | |||
| diagnosisReference | Reference(Condition) | |||
| detail | 0..* | Reference(Resource) | Product or service details | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |
| Documentation for this format | ||||
This structure is derived from CoverageEligibilityRequest
Differential View
This structure is derived from CoverageEligibilityRequest
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |
| identifier | 1..1 | Identifier | Business Identifier for coverage eligiblity request | |
| priority | 1..1 | CodeableConcept | Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred. | |
| enterer | 1..1 | Reference(Practitioner | PractitionerRole) | Author | |
| provider | 1..1 | Reference(Practitioner | Organization) | Party responsible for the request | |
| insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer Binding: https://swasth-digital-health-foundation.github.io/standards/output/ValueSet-insurance-company-owners.html (example): Insurance Company Owners |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| CoverageEligibilityRequest | 0..* | CoverageEligibilityRequest | CoverageEligibilityRequest resource | |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | 1..1 | Identifier | Business Identifier for coverage eligiblity request | |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| priority | 1..1 | CodeableConcept | Desired processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: STAT, normal, Deferred. | |
| purpose | Σ | 1..* | code | auth-requirements | benefits | discovery | validation Binding: EligibilityRequestPurpose (required): A code specifying the types of information being requested. |
| patient | Σ | 1..1 | Reference(Patient) | Intended recipient of products and services |
| serviced[x] | 0..1 | Estimated date or dates of service | ||
| servicedDate | date | |||
| servicedPeriod | Period | |||
| created | Σ | 1..1 | dateTime | Creation date |
| enterer | 1..1 | Reference(Practitioner | PractitionerRole) | Author | |
| provider | 1..1 | Reference(Practitioner | Organization) | Party responsible for the request | |
| insurer | Σ | 1..1 | Reference(Organization) | Coverage issuer |
| facility | 0..1 | Reference(Location) | Servicing facility | |
| supportingInfo | 0..* | BackboneElement | Supporting information | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| information | 1..1 | Reference(Resource) | Data to be provided | |
| appliesToAll | 0..1 | boolean | Applies to all items | |
| insurance | 0..* | BackboneElement | Patient insurance information | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | 0..1 | boolean | Applicable coverage | |
| coverage | 1..1 | Reference(Coverage) | Insurance information | |
| businessArrangement | 0..1 | string | Additional provider contract number | |
| item | 0..* | BackboneElement | Item to be evaluated for eligibiity | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| supportingInfoSequence | 0..* | positiveInt | Applicable exception or supporting information | |
| category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc. | |
| productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
| provider | 0..1 | Reference(Practitioner | PractitionerRole) | Perfoming practitioner | |
| quantity | 0..1 | SimpleQuantity | Count of products or services | |
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |
| facility | 0..1 | Reference(Location | Organization) | Servicing facility | |
| diagnosis | 0..* | BackboneElement | Applicable diagnosis | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| diagnosis[x] | 0..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||
| diagnosisCodeableConcept | CodeableConcept | |||
| diagnosisReference | Reference(Condition) | |||
| detail | 0..* | Reference(Resource) | Product or service details | |
| Documentation for this format | ||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet |
| CoverageEligibilityRequest.language | preferred | CommonLanguages Max Binding: AllLanguages |
| CoverageEligibilityRequest.status | required | FinancialResourceStatusCodes |
| CoverageEligibilityRequest.priority | example | ProcessPriorityCodes |
| CoverageEligibilityRequest.purpose | required | EligibilityRequestPurpose |
| CoverageEligibilityRequest.item.category | example | BenefitCategoryCodes |
| CoverageEligibilityRequest.item.productOrService | example | USCLSCodes |
| CoverageEligibilityRequest.item.modifier | example | ModifierTypeCodes |
| CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | example | ICD-10Codes |
| Id | Path | Details | Requirements |
| dom-2 | CoverageEligibilityRequest | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | CoverageEligibilityRequest | 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() | |
| dom-4 | CoverageEligibilityRequest | 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() | |
| dom-5 | CoverageEligibilityRequest | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | CoverageEligibilityRequest | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | CoverageEligibilityRequest.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.priority | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.purpose | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.patient | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.serviced[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.created | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.enterer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.provider | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.insurer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.facility | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.supportingInfo | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.supportingInfo.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.supportingInfo.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.supportingInfo.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.supportingInfo.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.supportingInfo.sequence | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.supportingInfo.information | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.supportingInfo.appliesToAll | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.insurance | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.insurance.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.insurance.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.insurance.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.insurance.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.insurance.focal | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.insurance.coverage | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.insurance.businessArrangement | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.item.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.item.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.item.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.item.supportingInfoSequence | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.productOrService | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.modifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.provider | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.quantity | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.unitPrice | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.facility | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.diagnosis | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.diagnosis.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.item.diagnosis.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.item.diagnosis.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | CoverageEligibilityRequest.item.diagnosis.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | CoverageEligibilityRequest.item.diagnosis.diagnosis[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | CoverageEligibilityRequest.item.detail | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |