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CoverageEligibilityRequest
$submit

CoverageEligibilityRequest $submit

post/CoverageEligibilityRequest/$submit
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This resource contains a patient’s eligibility details to identify which services, equipment, or prescriptions may be covered for a patient, typically prior to a visit.

As a healthcare organization, you can use this resource to determine estimates or quotes, as well as a patient’s financial responsibility, prior to a visit or order. The payer, employer, or other entity processes the eligibility request and returns a general summary of the patient’s benefits or a quote based on the patient’s insurance plan using a CoverageEligibilityResponse resource type.

Keep in mind this is different from a preauthorization request. Learn more about preauthorization requests. This resource is only for submitting a coverage eligibility request.

$submit

This operation allows you to submit a coverage eligibility request to a payer, employer, or other entity responsible for insurance payments. A coverage eligibility request helps determine (a) whether the payer, employer, or other entity has a particular subscriber or dependent on file, and (b) the healthcare eligibility and/or benefit information about that subscriber and/or dependent. 

The response to the request will be a bundle based on CoverageEligibilityResponse.

Request parameters and payload

cURL request example

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curl 'https://api.redoxengine.com/fhir/R4/{destinationSlug}/{environmentFlag}/CoverageEligibilityRequest/$submit' \
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--request POST \
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--header 'Authorization: Bearer $API_TOKEN' \
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--header 'Content-Type: application/fhir+json' \
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--data '{
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  "resourceType": "Bundle",
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  "id": "RedoxCoverageEligibilityRequestBundleExample",
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  "type": "collection",
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  "identifier": {
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    "system": "urn:ietf:rfc:3986",
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    "value": "urn:uuid:d348a18d-3676-426b-8105-e36085a710e3"
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  },
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  "timestamp": "2021-09-02T18:47:15.916Z",
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  "entry": [
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    {
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      "resource": {
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        "resourceType": "CoverageEligibilityRequest",
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        "id": "check-123456789",
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        "status": "active",
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        "patient": {
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          "reference": "Patient/RedoxPABeneficiaryExample"
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        },
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        "created": "2022-01-18T16:27:49.101Z",
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        "servicedPeriod": {
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          "start": "2022-01-18T16:20:00.101Z",
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          "end": "2022-01-18T17:20:00.101Z"
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        },
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        "purpose": [
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          "benefits"
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        ],
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        "insurer": {
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          "reference": "Organization/RedoxPAInsurerOrganizationExample"
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        },
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        "provider": {
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          "reference": "Practitioner/RedoxPAPractitionerExamplePat"
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        },
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        "facility": {
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          "reference": "Location/RedoxLocationExample"
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        },
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        "priority": {
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          "coding": [
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            {
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              "code": "normal",
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              "system": "http://terminology.hl7.org/CodeSystem/processpriority"
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            }
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          ]
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        },
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        "insurance": [
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          {
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            "focal": true,
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            "coverage": {
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              "reference": "Coverage/RedoxPACoverageExample"
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            }
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          }
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        ],
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        "item": [
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          {
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            "category": {
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              "coding": [
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                {
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                  "code": "30",
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                  "system": "https://x12.org/codes/service-type-codes",
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                  "display": "Plan Coverage and General Benefits"
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                }
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              ]
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            }
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Patient",
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        "id": "RedoxPABeneficiaryExample",
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        "identifier": [
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          {
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            "system": "urn:redox:MRN",
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            "value": "M23462346"
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          }
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        ],
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        "name": [
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          {
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            "given": [
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              "Timothy",
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              "Paul"
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            ],
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            "family": "Bixby"
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          }
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        ],
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        "gender": "male",
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        "birthDate": "2008-01-06"
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Coverage",
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        "id": "RedoxPACoverageWithRelatedSubscriberExample",
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        "class": [
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          {
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            "type": {
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              "coding": [
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                {
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                  "code": "group",
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                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class"
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                }
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              ]
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            },
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            "value": "GRP2245"
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          }
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        ],
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        "status": "active",
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        "beneficiary": {
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          "reference": "Patient/RedoxPABeneficiaryExample"
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        },
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        "payor": [
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          {
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            "reference": "Organization/RedoxPAInsurerOrganizationExample"
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          }
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        ],
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        "subscriber": {
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          "reference": "RelatedPerson/RedoxPASubscriberExample"
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        },
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        "subscriberId": "M2346623"
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Organization",
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        "id": "RedoxPAInsurerOrganizationExample",
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        "active": true,
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        "name": "Aetna",
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        "address": [
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          {
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            "line": [
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              "PO Box 14080"
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            ],
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            "city": "Lexington",
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            "district": "Fayette",
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            "state": "KY",
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            "postalCode": "40512-4079",
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            "country": "USA"
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Practitioner",
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        "id": "RedoxPAPractitionerExamplePat",
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        "identifier": [
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          {
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            "system": "http://hl7.org/fhir/sid/us-npi",
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            "value": "4356789876"
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          }
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        ],
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        "name": [
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          {
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            "given": [
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              "Pat"
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            ],
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            "family": "Granite"
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          }
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        ],
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        "address": [
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          {
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            "line": [
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              "123 Main St."
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            ],
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            "city": "Madison",
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            "district": "Dane",
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            "state": "WI",
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            "postalCode": "53703",
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            "country": "USA"
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          }
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        ],
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        "telecom": [
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          {
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            "value": "+16085551234"
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "RelatedPerson",
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        "id": "RedoxPASubscriberExample",
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        "patient": {
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          "reference": "RedoxPABeneficiary"
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        },
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        "name": [
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          {
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            "given": [
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              "Barbara"
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            ],
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            "family": "Bixby"
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          }
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        ],
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        "relationship": [
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          {
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            "text": "Mother"
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Location",
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        "id": "RedoxLocationExample",
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        "name": "RHS Vista Oaks Clinic",
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        "type": [
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          {
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            "coding": [
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              {
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                "code": "OF",
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                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
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                "display": "Outpatient Facility"
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              }
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            ]
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          }
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        ],
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        "physicalType": {
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          "coding": [
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            {
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              "code": "bu",
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              "system": "http://terminology.hl7.org/CodeSystem/location-physical-type",
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              "display": "Building"
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            }
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          ]
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        }
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      }
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    }
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  ]
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}'

Request Body Schema

  • 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, Array of CoverageEligibilityRequest, Patient, Coverage, Location, Practitioner, RelatedPerson or 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.

    • 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, Array of 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
        Array of 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.

Response fields and example

Example Eligibility Response

1
{}
  • 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, Array of CoverageEligibilityResponse, Patient, Coverage, Location, Practitioner, RelatedPerson or Other

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

    • 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, Array of 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, Array of 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
          Array of object

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