CoverageEligibilityRequest | Medplum

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.

Elements

Name	Required	Type	Description
identifier		Identifier[]	Business Identifier for coverage eligibility request Details A unique identifier assigned to this coverage eligibility request.
status	✓	code	active \| cancelled \| draft \| entered-in-error Details The status of the resource instance. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
priority		CodeableConcept	Desired processing priority Details When the requestor expects the processor to complete processing.
purpose	✓	code[]	auth-requirements \| benefits \| discovery \| validation Details 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.
patient	✓	Reference< Patient >	Intended recipient of products and services Details The party who is the beneficiary of the supplied coverage and for whom eligibility is sought. 1..1.
serviced[x]		date, Period	Estimated date or dates of service Details The date or dates when the enclosed suite of services were performed or completed.
created	✓	dateTime	Creation date Details The date when this resource was created.
enterer		Reference< Practitioner \| PractitionerRole >	Author Details Person who created the request.
provider		Reference< Practitioner \| PractitionerRole \| Organization >	Party responsible for the request Details The provider which is responsible for the request. Typically this field would be 1..1 where this party is responsible for the eligibility request but not necessarily professionally responsible for the provision of the individual products and services listed below.
insurer	✓	Reference< Organization >	Coverage issuer Details The Insurer who issued the coverage in question and is the recipient of the request.
facility		Reference< Location >	Servicing facility Details Facility where the services are intended to be provided.
supportingInfo		CoverageEligibilityRequestSupportingInfo[]	Supporting information Details Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are multiple jurisdiction specific value sets which are required.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details 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.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details 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). 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.

Additional Information

Additional information regarding electronic coverage eligibility content and usage may be found at:

Financial Resource Status Lifecycle: how .status is used in the financial resources.
Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
Batches: how eClaims may handle batches of eligibility, claims and responses.
Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This includes how payors how request additional supporting information from providers.