CoverageEligibilityRequest $submit

This operation is used to submit an eligibility request to a destination (payer, employer, HMO) to determine: (a) whether that entity has a particular subscriber or dependent on file, and (b) the health care eligibility and/or benefit information about that subscriber and/or dependent. The response to the request will be a bundle based on CoverageEligibilityResponse.

Request Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: Bundle
type
required, string

Indicates the purpose of this bundle - how it is intended to be used.

Value: collection
entry
required, [CoverageEligibilityRequest, Patient, Coverage, Location, Practitioner, RelatedPerson, Other]

An array of FHIR resources. At a minimum, a CoverageEligibilityRequest should include the following entries:

  • CoverageEligibilityRequest - the most important part of the request - contains references to all other resources, and the query in item
  • Patient - the patient the claim is about
  • Organization - at least one resource representing the party responsible for making the claim. Additional organization resources may carry information such as pharmacy, payor, or policy holder.
  • Coverage - the patient's insurance

Additional resources such as RelatedPerson should be included in scenarios where the Patient is a dependent of the coverage holder.

Any of:
resource
required, object

The Resource for the entry. The purpose/meaning of the resource is determined by the Bundle.type.

resourceType
required, string

Identifies the type of the resource

Value: CoverageEligibilityRequest
id
required, string

The internal tracking identifier for this eligibility request. This id will be returned on the CoverageEligibilityResponse.

status
required, string

The status of the resource instance.

Possible Values: active, cancelled, draft, entered-in-error
purpose
required, [string]

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.

Possible Values: auth-requirements, benefits, discovery, validation
patient
required, object

The Patient that you want to run eligibility checks for. This may be different than the policy holder

Must be a resource of type Patient.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

created
required, string

The date when this resource was created.

insurer
required, object

The payer that the request should be submitted to.

Must be a resource of type Organization.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

insurance
[object]

Financial instruments for reimbursement for the health care products and services.

coverage
required, object

The patient's coverage that should be used to make the eligiblity determination.

Must be a resource of type Coverage.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

focal
boolean

A flag to indicate that this Coverage is to be used for evaluation of this request when set to true.

businessArrangement
string

A business agreement number established between the provider and the insurer for special business processing purposes.

post/CoverageEligibilityRequest/$submit
Example Eligibility Request
Response Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: Bundle
type
required, string

Indicates the purpose of this bundle - how it is intended to be used.

Value: collection
entry
required, [CoverageEligibilityResponse, Patient, Coverage, Location, Practitioner, RelatedPerson, Other]

Contains at least one CoverageEligibilityResponse and other resources relevant to the coverage check.

Any of:
resource
required, object

The Resource for the entry. The purpose/meaning of the resource is determined by the Bundle.type.

resourceType
required, string

Identifies the type of the resource

Value: CoverageEligibilityResponse
id
required, string

The internal tracking identifier for this eligibility request. This id will be returned on the CoverageEligibilityResponse.

status
required, string

The status of the resource instance.

Possible Values: active, cancelled, draft, entered-in-error
purpose
required, [string]

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.

Possible Values: auth-requirements, benefits, discovery, validation
patient
required, object

The Patient that the elgibility results are being reported for. This may be different than the policy holder

Must be a resource of type Patient.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

created
required, string

The date this resource was created.

request
required, object

The initial CoverageEligibilityRequest.

Must be a resource of type CoverageEligibilityRequest.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

outcome
required, string

The outcome of the request processing.

Possible Values: queued, complete, error, partial
insurer
required, object

The payer that the request should be submitted to.

Must be a resource of type Organization.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

insurance
required, [object]

Financial instruments for reimbursement for the health care products and services.

coverage
required, object

The coverage of the patient.

Must be a resource of type Coverage.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

item
[object]

Benefits and optionally current balances, and authorization details by category or service.

Example Eligibility Response