Home
API reference
FHIR® API
FHIR® resources
CoverageEligibilityResponse
$respond

CoverageEligibilityResponse $respond

post/CoverageEligibilityResponse/$respond
Page View

This resource contains information about a patient’s benefits and coverage for services, equipment, or prescriptions.

A payer may use this resource to respond to a coverage eligibility request sent by a healthcare organization.

This is different from a claim response. Learn about a claim response.

$respond

Send a response to a coverage eligibility request submitted by a healthcare organization.

Request parameters and payload

cURL request example

bash
1
curl 'https://api.redoxengine.com/fhir/R4/{destinationSlug}/{environmentFlag}/CoverageEligibilityResponse/$respond' \
2
--request POST \
3
--header 'Authorization: Bearer $API_TOKEN' \
4
--header 'Content-Type: application/fhir+json' \
5
--data '{
6
  "resourceType": "Bundle",
7
  "id": "RedoxCoverageEligibilityResponseBundleExample",
8
  "type": "collection",
9
  "identifier": {
10
    "system": "urn:ietf:rfc:3986",
11
    "value": "urn:uuid:d348a18d-3676-426b-8105-e36085a710e3"
12
  },
13
  "timestamp": "2021-09-02T18:47:15.916Z",
14
  "entry": [
15
    {
16
      "resource": {
17
        "resourceType": "CoverageEligibilityResponse",
18
        "id": "check-123456789",
19
        "status": "active",
20
        "patient": {
21
          "reference": "Patient/RedoxPABeneficiaryExample"
22
        },
23
        "created": "2022-01-18T16:27:49.101Z",
24
        "servicedPeriod": {
25
          "start": "2022-01-18T16:20:00.101Z",
26
          "end": "2022-01-18T17:20:00.101Z"
27
        },
28
        "purpose": [
29
          "benefits"
30
        ],
31
        "request": {
32
          "reference": "CoverageEligibilityRequest/check-123456789"
33
        },
34
        "outcome": "complete",
35
        "insurer": {
36
          "reference": "Organization/RedoxPAInsurerOrganizationExample"
37
        },
38
        "insurance": [
39
          {
40
            "coverage": {
41
              "reference": "Coverage/RedoxPACoverageExample"
42
            },
43
            "benefitPeriod": {
44
              "start": "2022-01-18T16:20:00.101Z",
45
              "end": "2023-01-18T17:20:00.101Z"
46
            },
47
            "item": [
48
              {
49
                "category": {
50
                  "coding": [
51
                    {
52
                      "code": "1",
53
                      "system": "https://x12.org/codes/service-type-codes",
54
                      "display": "Medical Care"
55
                    }
56
                  ]
57
                },
58
                "benefit": [
59
                  {
60
                    "type": {
61
                      "coding": [
62
                        {
63
                          "code": "benefit"
64
                        }
65
                      ]
66
                    }
67
                  },
68
                  {
69
                    "type": {
70
                      "coding": [
71
                        {
72
                          "code": "copay-maximum"
73
                        }
74
                      ]
75
                    },
76
                    "allowedMoney": {
77
                      "value": 20,
78
                      "currency": "USD"
79
                    }
80
                  }
81
                ]
82
              },
83
              {
84
                "category": {
85
                  "coding": [
86
                    {
87
                      "code": "33",
88
                      "system": "https://x12.org/codes/service-type-codes",
89
                      "display": "Chiropractic"
90
                    }
91
                  ]
92
                },
93
                "benefit": [
94
                  {
95
                    "type": {
96
                      "coding": [
97
                        {
98
                          "code": "benefit"
99
                        }
100
                      ]
101
                    }
102
                  },
103
                  {
104
                    "type": {
105
                      "coding": [
106
                        {
107
                          "code": "copay-maximum"
108
                        }
109
                      ]
110
                    },
111
                    "allowedMoney": {
112
                      "value": 20,
113
                      "currency": "USD"
114
                    }
115
                  }
116
                ]
117
              },
118
              {
119
                "category": {
120
                  "coding": [
121
                    {
122
                      "code": "35",
123
                      "system": "https://x12.org/codes/service-type-codes",
124
                      "display": "Dental Care"
125
                    }
126
                  ]
127
                },
128
                "benefit": [
129
                  {
130
                    "type": {
131
                      "coding": [
132
                        {
133
                          "code": "benefit"
134
                        }
135
                      ]
136
                    }
137
                  },
138
                  {
139
                    "type": {
140
                      "coding": [
141
                        {
142
                          "code": "copay-maximum"
143
                        }
144
                      ]
145
                    },
146
                    "allowedMoney": {
147
                      "value": 20,
148
                      "currency": "USD"
149
                    }
150
                  }
151
                ]
152
              },
153
              {
154
                "category": {
155
                  "coding": [
156
                    {
157
                      "code": "47",
158
                      "system": "https://x12.org/codes/service-type-codes",
159
                      "display": "Hospital"
160
                    }
161
                  ]
162
                },
163
                "benefit": [
164
                  {
165
                    "type": {
166
                      "coding": [
167
                        {
168
                          "code": "benefit"
169
                        }
170
                      ]
171
                    }
172
                  },
173
                  {
174
                    "type": {
175
                      "coding": [
176
                        {
177
                          "code": "copay-maximum"
178
                        }
179
                      ]
180
                    },
181
                    "allowedMoney": {
182
                      "value": 20,
183
                      "currency": "USD"
184
                    }
185
                  }
186
                ]
187
              },
188
              {
189
                "category": {
190
                  "coding": [
191
                    {
192
                      "code": "86",
193
                      "system": "https://x12.org/codes/service-type-codes",
194
                      "display": "Emergency Services"
195
                    }
196
                  ]
197
                },
198
                "benefit": [
199
                  {
200
                    "type": {
201
                      "coding": [
202
                        {
203
                          "code": "benefit"
204
                        }
205
                      ]
206
                    }
207
                  },
208
                  {
209
                    "type": {
210
                      "coding": [
211
                        {
212
                          "code": "copay-maximum"
213
                        }
214
                      ]
215
                    },
216
                    "allowedMoney": {
217
                      "value": 20,
218
                      "currency": "USD"
219
                    }
220
                  }
221
                ]
222
              }
223
            ]
224
          }
225
        ]
226
      }
227
    },
228
    {
229
      "resource": {
230
        "resourceType": "Patient",
231
        "id": "RedoxPABeneficiaryExample",
232
        "identifier": [
233
          {
234
            "system": "urn:redox:MRN",
235
            "value": "M23462346"
236
          }
237
        ],
238
        "name": [
239
          {
240
            "given": [
241
              "Timothy",
242
              "Paul"
243
            ],
244
            "family": "Bixby"
245
          }
246
        ],
247
        "gender": "male",
248
        "birthDate": "2008-01-06"
249
      }
250
    },
251
    {
252
      "resource": {
253
        "resourceType": "Coverage",
254
        "id": "RedoxPACoverageWithRelatedSubscriberExample",
255
        "class": [
256
          {
257
            "type": {
258
              "coding": [
259
                {
260
                  "code": "group",
261
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class"
262
                }
263
              ]
264
            },
265
            "value": "GRP2245"
266
          }
267
        ],
268
        "status": "active",
269
        "beneficiary": {
270
          "reference": "Patient/RedoxPABeneficiaryExample"
271
        },
272
        "payor": [
273
          {
274
            "reference": "Organization/RedoxPAInsurerOrganizationExample"
275
          }
276
        ],
277
        "subscriber": {
278
          "reference": "RelatedPerson/RedoxPASubscriberExample"
279
        },
280
        "subscriberId": "M2346623"
281
      }
282
    },
283
    {
284
      "resource": {
285
        "resourceType": "Organization",
286
        "id": "RedoxPAInsurerOrganizationExample",
287
        "active": true,
288
        "name": "Aetna",
289
        "address": [
290
          {
291
            "line": [
292
              "PO Box 14080"
293
            ],
294
            "city": "Lexington",
295
            "district": "Fayette",
296
            "state": "KY",
297
            "postalCode": "40512-4079",
298
            "country": "USA"
299
          }
300
        ]
301
      }
302
    },
303
    {
304
      "resource": {
305
        "resourceType": "Practitioner",
306
        "id": "RedoxPAPractitionerExamplePat",
307
        "identifier": [
308
          {
309
            "system": "http://hl7.org/fhir/sid/us-npi",
310
            "value": "4356789876"
311
          }
312
        ],
313
        "name": [
314
          {
315
            "given": [
316
              "Pat"
317
            ],
318
            "family": "Granite"
319
          }
320
        ],
321
        "address": [
322
          {
323
            "line": [
324
              "123 Main St."
325
            ],
326
            "city": "Madison",
327
            "district": "Dane",
328
            "state": "WI",
329
            "postalCode": "53703",
330
            "country": "USA"
331
          }
332
        ],
333
        "telecom": [
334
          {
335
            "value": "+16085551234"
336
          }
337
        ]
338
      }
339
    },
340
    {
341
      "resource": {
342
        "resourceType": "RelatedPerson",
343
        "id": "RedoxPASubscriberExample",
344
        "patient": {
345
          "reference": "Patient/RedoxPABeneficiaryExample"
346
        },
347
        "name": [
348
          {
349
            "given": [
350
              "Barbara"
351
            ],
352
            "family": "Bixby"
353
          }
354
        ],
355
        "relationship": [
356
          {
357
            "text": "Mother"
358
          }
359
        ]
360
      }
361
    },
362
    {
363
      "resource": {
364
        "resourceType": "Location",
365
        "id": "RedoxLocationExample",
366
        "name": "RHS Vista Oaks Clinic",
367
        "type": [
368
          {
369
            "coding": [
370
              {
371
                "code": "OF",
372
                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
373
                "display": "Outpatient Facility"
374
              }
375
            ]
376
          }
377
        ],
378
        "physicalType": {
379
          "coding": [
380
            {
381
              "code": "bu",
382
              "system": "http://terminology.hl7.org/CodeSystem/location-physical-type",
383
              "display": "Building"
384
            }
385
          ]
386
        }
387
      }
388
    }
389
  ],
390
  "Meta": {
391
    "Logs": [
392
      {
393
        "ID": "d9f5d293-7110-461e-a875-3beb089e79f3",
394
        "AttemptID": "925d1617-2fe0-468c-a14c-f8c04b572c54"
395
      }
396
    ],
397
    "Test": true,
398
    "EventDateTime": "2025-10-21T19:00:27.070Z",
399
    "Source": {
400
      "ID": "7ce6f387-c33c-417d-8682-81e83628cbd9",
401
      "Name": "Redox Dev Tools"
402
    },
403
    "Destinations": [
404
      {
405
        "ID": "af394f14-b34a-464f-8d24-895f370af4c9",
406
        "Name": "Redox EMR"
407
      }
408
    ],
409
    "DataModel": "FHIR.CoverageEligibilityResponse",
410
    "EventType": "$respond"
411
  }
412
}'

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 CoverageEligibilityResponse, Patient, Coverage, Location

    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.

    Response fields and example

    Example Eligibility Response
    json
    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

      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.