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Insurance eligibility checks determine whether a patient's insurance is active, in-network, and has applicable benefits. They ensure that the provider will ultimately get compensated by the patient's insurer for a specific product or service.
## Use Cases
Insurance eligibility checks cover a variety of use cases, but generally they are used to answer three questions:
1. Is this insurance active?
2. Does this insurance cover basic visits to a provider?
3. Does this insurance cover a specific service type?
The most basic use case for an eligibility check is simply seeing if the policy is active and in force.
Adding a second layer is checking if the policy is active and also covers basic visits to a provider. These include appointments like physicals and check-ups and is the most common type of eligibility request.
Because it is so common, these types of requests are defined by the [X12 Service Type Codes](https://x12.org/codes/service-type-codes) in **service code 30**. This service type is "Plan Coverage and General Benefits", and checks for active basic coverage.
Two common use cases for this service type are:
- Checking that a new patient's coverage is active and has general benefits.
- Checking coverage directly prior to a visit to ensure that the policy has not changed and the patient is still covered.
Finally, checking that insurance covers a specific service type adds a third layer to an eligibility check. These are done to ensure that a patient is covered for more complex care. It is recommended to use the [X12 Service Type Codes](https://x12.org/codes/service-type-codes) to illustrate the type of care that is being checked.
For example, if a patient needs to purchase durable medical equipment, you would use **service code 12**. This code represents "Durable Medical Equipment Purchased".
It is important to note that you should be checking the _service type_ to be provided, not the _specific service_, which is exactly what the [X12 Service Type Codes](https://x12.org/codes/service-type-codes) are designed to do.
## Preparing an Eligibility Check
FHIR follows a request/response pattern for eligibility checks. This uses two resources: the [`CoverageEligibilityRequest`](/content/docs/api/fhir/resources/coverageeligibilityrequest/index.html) to model the request to the insurer and the [`CoverageEligibilityResponse`](/content/docs/api/fhir/resources/coverageeligibilityresponse/index.html) to model their response.
To complete an eligibility check, you will need the following information:
- Patient demographic info, modeled as a reference to a [`Patient`](/content/docs/api/fhir/resources/patient/index.html) resource.
- Patient insurance coverage, modeled as a reference to a [`Coverage`](/content/docs/api/fhir/resources/coverage/index.html) resource (see our [insurance guide](/content/docs/billing/patient-insurance/index.html) for more info).
- Provider info, modeled as a reference to the relevant [`Practitioner`](/content/docs/api/fhir/resources/practitioner/index.html), [`PractitionerRole`](/content/docs/api/fhir/resources/practitionerrole/index.html), or [`Organization`](/content/docs/api/fhir/resources/organization/index.html) (see the [provider network guide](/content/docs/administration/provider-directory/provider-networks/index.html) for more info).
- The procedure/service to be provided and the diagnosis. This information should be on the relevant [`Encounter`](/content/docs/api/fhir/resources/encounter/index.html).
## Creating a Request
FHIR provides the [`CoverageEligibilityRequest`](/content/docs/api/fhir/resources/coverageeligibilityrequest/index.html) resource to model a request for an insurance eligibility check.
| **Element** | **Description** | **Code System** | **Example** |
| --- | --- | --- | --- |
| `patient` | A reference to the [`Patient`](/content/docs/api/fhir/resources/patient/index.html) the request is for. | | Patient/homer-simpson |
| `provider` | A reference to the [`Practitioner`](/content/docs/api/fhir/resources/practitioner/index.html) or [`Organization`](/content/docs/api/fhir/resources/organization/index.html) that will be providing the service. This is the party that is submitting the request, but is not necessarily the specific [`Practitioner`](/content/docs/api/fhir/resources/practitioner/index.html) who will be providing the service detailed within. | | Practitioner/dr-alice-smith |
| `insurer` | A reference to the insurance [`Organization`](/content/docs/api/fhir/resources/organization/index.html) that is providing coverage and will be evaluating the request. | | Organization/blue-cross |
| `purpose` | The reason the request is being made. Must be one of the following:
- `auth-requirements`: A check of prior authorization that is required for the specified product or service.
- `benefits`: The benefits on the plan or the benefits consumed by the specified product or service.
- `discovery`: A request for the insurer to report any coverages they are aware of in addition to the ones specified.
- `validation`: A check that the specified coverages are in-force. | | validation |
| `insurance.coverage` | A reference to the [`Coverage`](/content/docs/api/fhir/resources/coverage/index.html) resource that is being checked. | | Coverage/example-coverage |
| `item` | Details about the items, services, or procedures for which eligibility is being checked. | | [See below](/content/docs/billing/insurance-eligibility-checks#the-item-being-checked-for-coverage/index.html) |
| `status` | The status of the request. | | active |
| `supportingInfo` | Additional information about the request. This could include a patient's condition, more details about the situation, special considerations, or more. | | |
### The Item Being Checked for Coverage
As mentioned in the table above, the `item` element provides details about the eligibility being checked. This includes what procedure, product, or service is being provided as well as _why_ it is being provided.
The `item` field also provides additional data about the procedure, product, or service.
| **Property** | **Description** | **Code System** | **Example** |
| --- | --- | --- | --- |
| `category` | The general type of the service or product being checked for eligibility. | [X12 Codes](https://x12.org/codes/service-type-codes) | Vision Coverage |
| `productOrService` | The product, drug, service, etc. that is being provided. | [CPT Codes](https://www.ama-assn.org/topics/cpt-codes) | 92340 - Fitting of eyeglasses |
| `diagnosis` | The diagnosis for which care is being sought. | [ICD-10 Codes](https://www.icd10data.com/ICD10CM/Codes) | Condition/reduced-vision |
| `provider` | A reference to the [`Practitioner`](/content/docs/api/fhir/resources/practitioner/index.html) who is responsible for providing the service. | | Practitioner/dr-alice-smith |
| `quantity` | The number of repetitions of the service that will be performed. | | 2 |
| `unitPrice` | The price charged to the patient for a single unit of the service. This is the price that the provider charges for the service. | | $200 |
| `facility` | A reference to the [`Location`](/content/docs/api/fhir/resources/location/index.html) or [`Organization`](/content/docs/api/fhir/resources/organization/index.html) where the service will be provided. | | Organization/example-hospital |
| `detail` | A reference to the [`CarePlan`](/content/docs/api/fhir/resources/careplan/index.html) with details describing the service. | | CarePlan/improve-vision |
Example: A coverage eligibility request for a consultation
```ts
{
resourceType: 'CoverageEligibilityRequest',
id: 'coverage-validation-request',
status: 'active',
purpose: ['validation'],
created: '2021-01-01T00:00:00.000Z',
patient: {
reference: 'Patient/homer-simpson',
},
provider: {
reference: 'Practitioner/dr-alice-smith',
},
insurer: {
reference: 'Organization/blue-cross-blue-shield',
},
insurance: [
{
coverage: {
reference: 'Coverage/homer-simpson-coverage',
},
},
],
item: [
{
category: {
coding: [
{
system: 'https://x12.org/codes/service-type-codes',
code: '3',
display: 'Consultation',
},
],
},
productOrService: {
coding: [
{
system: 'http://www.ama-assn.org/go/cpt',
code: '80504',
display: 'Consultation for a moderately complex clinical problem',
},
],
},
},
],
};
```
Example: A plan coverage and general benefits check
```ts
{
resourceType: 'CoverageEligibilityRequest',
id: 'general-benefits-check',
status: 'active',
purpose: ['benefits', 'discovery'],
created: '2021-01-01T00:00:00.000Z',
patient: {
reference: 'Patient/jane-doe',
},
provider: {
reference: 'Organization/example-hospital',
},
insurer: {
reference: 'Organization/kaiser-permanente',
},
insurance: [
{
coverage: {
reference: 'Coverage/jane-doe-coverage',
},
},
],
item: [
{
category: {
coding: [
{
system: 'https://x12.org/codes/service-type-codes',
code: '30',
display: 'Plan Coverage and General Benefits',
},
],
},
},
],
};
```
## Sending an Eligibility Check Request
Once you have created your [`CoverageEligibilityRequest`](/content/docs/api/fhir/resources/coverageeligibilityrequest/index.html), you need to send it to the insurer.
In addition to sending it directly to the insurer, there are services that simplify the process. Companies such as [Opkit](https://www.opkit.co/), [Availity](https://www.availity.com/), [Change Healthcare](https://www.changehealthcare.com/), [Waystar](https://www.waystar.com/) and [Candid Health](https://www.joincandidhealth.com/) allow you to send them eligibility checks directly.
Unfortunately, these companies format their requests based on [X12 EDI Format](https://x12.org/examples/005010x279) rather than FHIR, so you will need to convert your [`CoverageEligibilityRequest`](/content/docs/api/fhir/resources/coverageeligibilityrequest/index.html) to the correct format. This is a good workflow to implement [Bots](/content/docs/bots/bot-basics/index.html) to convert your request, interface with the company's API, and send the request. Additionally, you can have a [Subscription](/content/docs/subscriptions/index.html) to listen for a response and have a bot handle that as well.
## Receiving a Response
When you send your request, the insurer will review it and respond. This response will be modeled as a [`CoverageEligibilityResponse`](/content/docs/api/fhir/resources/coverageeligibilityresponse/index.html).
| **Element** | **Description** | **Example** |
| --- | --- | --- |
| `outcome` | The outcome of the _processing_ of the request. Does NOT answer if the patient is eligible for coverage. | complete |
| `disposition` | A human-readable description of the status of the request. | The policy is currently in-force. |
| `error` | Documents any errors that encountered during the eligibility check. Describes why a check may not have been able to be completed. | Missing Identifier |
| `insurance.item` | Details about the benefits, authorization requirements, and current benefits of the insurance. | [See below](/content/docs/billing/insurance-eligibility-checks#the-item-being-checked-for-coverage/index.html) |
| `insurance.inforce` | A boolean indicating if the coverage is in force for the requested period. | true |
| `insurance.benefitPeriod` | The term period of the benefits documented in the response. | 2023-01-01 – 2023-12-31 |
| `insurance.coverage` | A reference to the patient's [`Coverage`](/content/docs/api/fhir/resources/coverage/index.html) resource. | Coverage/example-coverage |
| `request` | A reference to the original [`CoverageEligibilityRequest`](/content/docs/api/fhir/resources/coverageeligibilityrequest/index.html) this is in response to. | CoverageEligibilityRequest/check-for-vision-coverage |
| `purpose` | The reason the initial request was made. [See the `purpose` field in the above table](/content/docs/billing/insurance-eligibility-checks#creating-a-request/index.html) for the allowed valueset. | validation |
| `status` | The status of the response. | active |
| `insurer` | A reference to the [`Organization`](/content/docs/api/fhir/resources/organization/index.html) that is providing coverage and that sent the response. | Organization/blue-cross |
| `patient` | A reference to the [`Patient`](/content/docs/api/fhir/resources/patient/index.html) the response is for. | Patient/homer-simpson |
### The Covered Items
Like its request counterpart, the [`CoverageEligibilityResponse`](/content/docs/api/fhir/resources/coverageeligibilityresponse/index.html) also has an `item` element, however it is a property on the `insurance` element rather than directly on the resource (e.g. `CoverageEligibilityResponse.insurance.item` vs `CoverageEligibilityRequest.item`). The `item` property contains details about allowed products and services under the insurance policy.
This field has some overlap with the request resource, but there are also significant differences between the two.
| **Property** | **Description** | **Code System** | **Example** |
| --- | --- | --- | --- |
| `benefit` | A description of the benefits allowed and used to date under the coverage. | | allowedMoney: $10000, usedMoney: $645.99 |
| `description` | A more detailed description of the benefits or services that are covered. | | Vision is covered in this policy. |
| `authorizationRequired` | A boolean indicating if authorization is required before providing service. | | true |
| `authorizationSupporting` | Details about additional information or material needed to get authorization. | [`CoverageEligibilityResponse` Auth Support Codes](https://build.fhir.org/valueset-coverageeligibilityresponse-ex-auth-support.html) | Lab Report |
| `excluded` | A boolean indicating if the service is excluded from the plan. | | false |
| `network` | Indicates whether the benefits apply to in-network or out-of-network providers. | [Network Type Codes](https://build.fhir.org/valueset-benefit-network.html) | in |
| `unit` | Indicates whether the benefits apply to an individual or to a family. | [Unit Type Codes](https://build.fhir.org/valueset-benefit-unit.html) | individual |
| `term` | The term or duration during which service is covered. | [Benefit Term Codes](https://build.fhir.org/valueset-benefit-term.html) | annual |
| `productOrService` | The product, drug, service, etc. that is being provided. | [CPT Codes](https://www.ama-assn.org/topics/cpt-codes) | 92340 - Fitting of eyeglasses |
| `provider` | A reference to the [`Practitioner`](/content/docs/api/fhir/resources/practitioner/index.html) who is responsible for providing the service. | | Practitioner/dr-alice-smith |
| `category` | The general type of the service or product being checked for eligibility. | | Vision Coverage |
Coordination of Benefits
FHIR makes the `insurance` field on both the request and response an array, allowing for coordination of benefits across multiple insurance policies.
When sending a request, if there are multiple insurances, the `CoverageEligibilityRequest.insurance.focal` field should be set to `true` on the specific coverage being checked.
The `item` field is also an array on the `insurance` element of a [`CoverageEligibilityResponse`](/content/docs/api/fhir/resources/coverageeligibilityresponse/index.html) because it can represent multiple items that are covered under a specific insurance. When coordinating care among multiple policies, it can be common for multiple items from multiple coverages to be relevant to the check.
Example: A coverage eligibility response for a basic consultation
```ts
{
resourceType: 'CoverageEligibilityResponse',
status: 'active',
purpose: ['validation'],
created: '2021-01-01T00:00:00.000Z',
patient: {
reference: 'Patient/homer-simpson',
},
request: {
reference: 'CoverageEligibilityRequest/coverage-validation-request',
},
outcome: 'complete',
disposition: 'Coverage is currently in-force',
insurer: {
reference: 'Organization/blue-cross-blue-shield',
},
insurance: [
{
coverage: {
reference: 'Coverage/homer-simpson-coverage',
},
inforce: true,
item: [
{
category: {
coding: [
{
system: 'https://x12.org/codes/service-type-codes',
code: '3',
display: 'Consultation',
},
],
},
network: {
coding: [
{
system: 'http://terminology.hl7.org/CodeSystem/benefit-network',
code: 'in',
},
],
},
unit: {
coding: [
{
system: 'http://terminology.hl7.org/CodeSystem/benefit-unit',
code: 'individual',
},
],
},
term: {
coding: [
{
system: 'http://terminology.hl7.org/CodeSystem/benefit-term',
code: 'annual',
},
],
},
benefit: [
{
type: {
coding: [
{
code: 'copay-maximum',
},
],
},
allowedMoney: {
value: 100,
currency: 'USD',
},
},
],
},
],
},
],
};
```
Example: A plan coverage and general benefits check response
```ts
{
resourceType: 'CoverageEligibilityResponse',
status: 'active',
purpose: ['benefits', 'discovery'],
created: '2021-01-01T00:00:00.000Z',
patient: {
reference: 'Patient/jane-doe',
},
request: {
reference: 'CoverageEligibilityRequest/general-benefits-check',
},
outcome: 'complete',
disposition: 'Coverage is currently in-force',
insurer: {
reference: 'Organization/kaiser-permanente',
},
insurance: [
{
coverage: {
reference: 'Coverage/jane-doe-coverage',
},
inforce: true,
item: [
{
category: {
coding: [
{
system: 'https://x12.org/codes/service-type-codes',
code: '30',
display: 'Plan Coverage and General Benefits',
},
],
},
},
],
},
],
};
```