openIMIS FHIR R4 Implementation Guide
1.0.0 - ci-build

openIMIS FHIR R4 Implementation Guide - Local Development build (v1.0.0). See the Directory of published versions

Resource Profile: openIMIS CoverageEligibilityResponse

Official URL: https://openimis.github.io/openimis_fhir_r4_ig/StructureDefinition/openimis-coverage-eligibility-response Version: 1.0.0
Active as of 2022-05-31 Responsible: openIMIS Initiative Computable Name: OpenIMISCoverageEligibilityResponse

Defines a CoverageEligibilityResponse for openIMIS to get the enquire information for an Insuree.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CoverageEligibilityResponse

Summary

Mandatory: 4 elements (18 nested mandatory elements)
Prohibited: 23 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element CoverageEligibilityResponse.identifier is sliced based on the value of value:type.coding.code (Closed)
  • The element CoverageEligibilityResponse.insurance.item is sliced based on the value of value:category.coding.code (Closed)
  • The element CoverageEligibilityResponse.insurance.item.benefit is sliced based on the value of type:allowed[x] (Closed)
  • The element CoverageEligibilityResponse.insurance.item.benefit.allowed[x] is sliced based on the value of type:$this
  • The element CoverageEligibilityResponse.insurance.item.benefit is sliced based on the value of value:type.coding.code (Closed)

This structure is derived from CoverageEligibilityResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..*CoverageEligibilityResponseCoverageEligibilityResponse resource
... Slices for identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
Slice: Unordered, Closed by value:type.coding.code
.... identifier:All Slices Content/Rules for all slices
..... type 1..1CodeableConceptDescription of identifier
...... coding
....... code 0..1codeSymbol in syntax defined by the system
Binding: openIMIS Identifiers Value Set (required)
..... value 1..1stringThe value that is unique
.... identifier:UUID 1..1IdentifierBusiness Identifier for coverage eligiblity request
..... type
...... coding
....... code 1..1codeExternal System generated UUID
Required Pattern: UUID
... status 1..1codeactive | cancelled | draft | entered-in-error
Required Pattern: active
... purpose 1..1codeauth-requirements | benefits | discovery | validation
Required Pattern: benefits
... serviced[x] 0..0
... requestor 0..0
... request 1..1Reference(openIMIS CoverageEligibilityRequest)Eligibility request reference
... outcome 1..1codequeued | complete | error | partial
Required Pattern: complete
... disposition 0..0
... insurer 1..1Reference(openIMIS Insurance Organization)Coverage issuer
... insurance
.... coverage 1..1Reference(openIMIS Coverage)Insurance information
.... inforce 0..0
.... benefitPeriod 1..1PeriodWhen the benefits are applicable
..... start 1..1dateTimeBenefit stat day
..... end 1..1dateTimeBenefit end day
.... Slices for item 1..3BackboneElementBenefits and authorization details
Slice: Unordered, Closed by value:category.coding.code
..... item:All Slices Content/Rules for all slices
...... category 0..1CodeableConceptCategory
Binding: Category of the item (Coverage) (required)
...... modifier 0..0
...... provider 0..0
...... network 0..0
...... unit 0..0
...... term 0..0
...... authorizationRequired 0..0
...... authorizationSupporting 0..0
...... authorizationUrl 0..0
..... item:benefit 1..1BackboneElementCoverage eligibility for policy
...... category 0..1CodeableConceptBenefit classification
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-category
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
........ display1..1stringRepresentation defined by the system
Fixed Value: Benefit Package
...... productOrService 0..0
...... excluded 0..0
...... name 1..1stringProduct/Item/Service code
...... description 1..1stringProduct/Item/Service name
...... Slices for benefit 0..11BackboneElementBenefit Summary
Slice: Unordered, Closed by type:allowed[x]
....... benefit:All Slices Content/Rules for all slices
........ used[x] 0..0
....... benefit:total 0..6BackboneElementBenefit Summary
........ type 1..1CodeableConceptBenefit classification
Binding: Type of benefit as total left (Coverage) (required)
........ allowed[x] 1..1unsignedIntBenefits allowed
....... benefit:amount 0..5BackboneElementBenefit Summary
........ type 1..1CodeableConceptBenefit classification
Binding: Type of benefit as amount left (Coverage) (required)
........ allowed[x] 1..1MoneyBenefits allowed
Slice: Unordered, Open by type:$this
........ allowedMoney 1..1MoneyBenefits allowed
......... value 1..1decimalNumerical value (with implicit precision)
..... item:item 0..1BackboneElementCoverage eligibility for item
...... category 0..1CodeableConceptBenefit classification
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-category
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: item
........ display1..1stringRepresentation defined by the system
Fixed Value: Item
...... productOrService 1..1CodeableConceptItem Code
....... coding 0..0
....... text 1..1stringItem Code
...... excluded 1..1booleanItem excluded
...... Slices for benefit 0..2BackboneElementBenefit Summary
Slice: Unordered, Closed by value:type.coding.code
....... benefit:All Slices Content/Rules for all slices
........ used[x] 0..0
....... benefit:minDate 0..1BackboneElementBenefit Summary
........ type 1..1CodeableConceptBenefit classification
Required Pattern: At least the following
......... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
.......... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-benefit-type
.......... code1..1codeSymbol in syntax defined by the system
Fixed Value: min_date_item
.......... display1..1stringRepresentation defined by the system
Fixed Value: Mininum date
........ allowed[x] 0..1stringBenefits allowed
....... benefit:itemLeft 0..1BackboneElementBenefit Summary
........ type 1..1CodeableConceptBenefit classification
Required Pattern: At least the following
......... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
.......... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-benefit-type
.......... code1..1codeSymbol in syntax defined by the system
Fixed Value: item_left
.......... display1..1stringRepresentation defined by the system
Fixed Value: Items left
........ allowed[x] 0..1unsignedIntBenefits allowed
..... item:service 0..1BackboneElementCoverage eligibility for service
...... category 0..1CodeableConceptBenefit classification
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-category
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: service
........ display1..1stringRepresentation defined by the system
Fixed Value: Service
...... productOrService 1..1CodeableConceptService Code
....... coding 0..0
....... text 1..1stringService Code
...... excluded 1..1booleanService excluded
...... Slices for benefit 0..2BackboneElementBenefit Summary
Slice: Unordered, Closed by value:type.coding.code
....... benefit:minDate 0..1BackboneElementBenefit Summary
........ type 1..1CodeableConceptBenefit classification
Required Pattern: At least the following
......... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
.......... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-benefit-type
.......... code1..1codeSymbol in syntax defined by the system
Fixed Value: min_date_item
.......... display1..1stringRepresentation defined by the system
Fixed Value: Mininum date
........ allowed[x] 0..1stringBenefits allowed
........ used[x] 0..0
....... benefit:itemLeft 0..1BackboneElementBenefit Summary
........ type 1..1CodeableConceptBenefit classification
Required Pattern: At least the following
......... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
.......... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-benefit-type
.......... code1..1codeSymbol in syntax defined by the system
Fixed Value: item_left
.......... display1..1stringRepresentation defined by the system
Fixed Value: Items left
........ allowed[x] 0..1unsignedIntBenefits allowed
........ used[x] 0..0
... preAuthRef 0..0
... form 0..0
... error 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..*CoverageEligibilityResponseCoverageEligibilityResponse resource
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
Slice: Unordered, Closed by value:type.coding.code
.... identifier:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ0..1codeSymbol in syntax defined by the system
Binding: openIMIS Identifiers Value Set (required)
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... identifier:UUID 1..1IdentifierBusiness Identifier for coverage eligiblity request
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeExternal System generated UUID
Required Pattern: UUID
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... purpose Σ1..1codeauth-requirements | benefits | discovery | validation
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.



Required Pattern: benefits
... patient Σ1..1Reference(openIMIS Patient)Intended recipient of products and services
... created Σ1..1dateTimeResponse creation date
... request Σ1..1Reference(openIMIS CoverageEligibilityRequest)Eligibility request reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The outcome of the processing.


Required Pattern: complete
... insurer Σ1..1Reference(openIMIS Insurance Organization)Coverage issuer
... insurance 0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... coverage Σ1..1Reference(openIMIS Coverage)Insurance information
.... benefitPeriod 1..1PeriodWhen the benefits are applicable
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣI1..1dateTimeBenefit stat day
..... end ΣI1..1dateTimeBenefit end day
.... Slices for item I1..3BackboneElementBenefits and authorization details
Slice: Unordered, Closed by value:category.coding.code
..... item:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 0..1CodeableConceptCategory
Binding: Category of the item (Coverage) (required)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... excluded 0..1booleanExcluded from the plan
...... name 0..1stringShort name for the benefit
...... description 0..1stringDescription of the benefit or services covered
...... benefit 0..*BackboneElementBenefit Summary
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
....... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

....... allowed[x] 0..1Benefits allowed
........ allowedUnsignedIntunsignedInt
........ allowedStringstring
........ allowedMoneyMoney
....... used[x] 0..1Benefits used
........ usedUnsignedIntunsignedInt
........ usedStringstring
........ usedMoneyMoney
..... item:benefit I1..1BackboneElementCoverage eligibility for policy
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-category
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
........ display1..1stringRepresentation defined by the system
Fixed Value: Benefit Package
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... provider 0..1Reference(Practitioner | PractitionerRole)Performing practitioner
...... name 1..1stringProduct/Item/Service code
...... description 1..1stringProduct/Item/Service name
...... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

...... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

...... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

...... Slices for benefit 0..11BackboneElementBenefit Summary
Slice: Unordered, Closed by type:allowed[x]
....... benefit:All Slices Content/Rules for all slices
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

........ allowed[x] 0..1Benefits allowed
......... allowedUnsignedIntunsignedInt
......... allowedStringstring
......... allowedMoneyMoney
....... benefit:total 0..6BackboneElementBenefit Summary
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: Type of benefit as total left (Coverage) (required)
........ allowed[x] 1..1unsignedIntBenefits allowed
........ used[x] 0..1Benefits used
......... usedUnsignedIntunsignedInt
......... usedStringstring
......... usedMoneyMoney
....... benefit:amount 0..5BackboneElementBenefit Summary
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: Type of benefit as amount left (Coverage) (required)
........ Slices for allowed[x] 1..1MoneyBenefits allowed
Slice: Unordered, Closed by type:$this
......... allowed[x]:allowedMoney 1..1MoneyBenefits allowed
.......... id 0..1stringUnique id for inter-element referencing
.......... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.......... value Σ1..1decimalNumerical value (with implicit precision)
.......... currency Σ0..1codeISO 4217 Currency Code
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

........ used[x] 0..1Benefits used
......... usedUnsignedIntunsignedInt
......... usedStringstring
......... usedMoneyMoney
...... authorizationRequired 0..1booleanAuthorization required flag
...... authorizationSupporting 0..*CodeableConceptType of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


...... authorizationUrl 0..1uriPreauthorization requirements endpoint
..... item:item I0..1BackboneElementCoverage eligibility for item
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-category
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: item
........ display1..1stringRepresentation defined by the system
Fixed Value: Item
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... productOrService 1..1CodeableConceptItem Code
Binding: USCLSCodes (example): Allowable service and product codes.

....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... text Σ1..1stringItem Code
...... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... provider 0..1Reference(Practitioner | PractitionerRole)Performing practitioner
...... excluded 1..1booleanItem excluded
...... name 0..1stringShort name for the benefit
...... description 0..1stringDescription of the benefit or services covered
...... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

...... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

...... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

...... Slices for benefit 0..2BackboneElementBenefit Summary
Slice: Unordered, Closed by value:type.coding.code
....... benefit:All Slices Content/Rules for all slices
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

........ allowed[x] 0..1Benefits allowed
......... allowedUnsignedIntunsignedInt
......... allowedStringstring
......... allowedMoneyMoney
....... benefit:minDate 0..1BackboneElementBenefit Summary
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.


Required Pattern: At least the following
......... id0..1stringUnique id for inter-element referencing
......... extension0..*ExtensionAdditional content defined by implementations
......... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
.......... id0..1stringUnique id for inter-element referencing
.......... extension0..*ExtensionAdditional content defined by implementations
.......... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-benefit-type
.......... version0..1stringVersion of the system - if relevant
.......... code1..1codeSymbol in syntax defined by the system
Fixed Value: min_date_item
.......... display1..1stringRepresentation defined by the system
Fixed Value: Mininum date
.......... userSelected0..1booleanIf this coding was chosen directly by the user
......... text0..1stringPlain text representation of the concept
........ allowed[x] 0..1stringBenefits allowed
........ used[x] 0..1Benefits used
......... usedUnsignedIntunsignedInt
......... usedStringstring
......... usedMoneyMoney
....... benefit:itemLeft 0..1BackboneElementBenefit Summary
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.


Required Pattern: At least the following
......... id0..1stringUnique id for inter-element referencing
......... extension0..*ExtensionAdditional content defined by implementations
......... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
.......... id0..1stringUnique id for inter-element referencing
.......... extension0..*ExtensionAdditional content defined by implementations
.......... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-benefit-type
.......... version0..1stringVersion of the system - if relevant
.......... code1..1codeSymbol in syntax defined by the system
Fixed Value: item_left
.......... display1..1stringRepresentation defined by the system
Fixed Value: Items left
.......... userSelected0..1booleanIf this coding was chosen directly by the user
......... text0..1stringPlain text representation of the concept
........ allowed[x] 0..1unsignedIntBenefits allowed
........ used[x] 0..1Benefits used
......... usedUnsignedIntunsignedInt
......... usedStringstring
......... usedMoneyMoney
...... authorizationRequired 0..1booleanAuthorization required flag
...... authorizationSupporting 0..*CodeableConceptType of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


...... authorizationUrl 0..1uriPreauthorization requirements endpoint
..... item:service I0..1BackboneElementCoverage eligibility for service
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-category
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: service
........ display1..1stringRepresentation defined by the system
Fixed Value: Service
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... productOrService 1..1CodeableConceptService Code
Binding: USCLSCodes (example): Allowable service and product codes.

....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... text Σ1..1stringService Code
...... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... provider 0..1Reference(Practitioner | PractitionerRole)Performing practitioner
...... excluded 1..1booleanService excluded
...... name 0..1stringShort name for the benefit
...... description 0..1stringDescription of the benefit or services covered
...... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

...... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

...... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

...... Slices for benefit 0..2BackboneElementBenefit Summary
Slice: Unordered, Closed by value:type.coding.code
....... benefit:All Slices Content/Rules for all slices
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

........ allowed[x] 0..1Benefits allowed
......... allowedUnsignedIntunsignedInt
......... allowedStringstring
......... allowedMoneyMoney
........ used[x] 0..1Benefits used
......... usedUnsignedIntunsignedInt
......... usedStringstring
......... usedMoneyMoney
....... benefit:minDate 0..1BackboneElementBenefit Summary
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.


Required Pattern: At least the following
......... id0..1stringUnique id for inter-element referencing
......... extension0..*ExtensionAdditional content defined by implementations
......... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
.......... id0..1stringUnique id for inter-element referencing
.......... extension0..*ExtensionAdditional content defined by implementations
.......... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-benefit-type
.......... version0..1stringVersion of the system - if relevant
.......... code1..1codeSymbol in syntax defined by the system
Fixed Value: min_date_item
.......... display1..1stringRepresentation defined by the system
Fixed Value: Mininum date
.......... userSelected0..1booleanIf this coding was chosen directly by the user
......... text0..1stringPlain text representation of the concept
........ allowed[x] 0..1stringBenefits allowed
....... benefit:itemLeft 0..1BackboneElementBenefit Summary
........ id 0..1stringUnique id for inter-element referencing
........ extension 0..*ExtensionAdditional content defined by implementations
........ modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
........ type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.


Required Pattern: At least the following
......... id0..1stringUnique id for inter-element referencing
......... extension0..*ExtensionAdditional content defined by implementations
......... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
.......... id0..1stringUnique id for inter-element referencing
.......... extension0..*ExtensionAdditional content defined by implementations
.......... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/coverage-item-benefit-type
.......... version0..1stringVersion of the system - if relevant
.......... code1..1codeSymbol in syntax defined by the system
Fixed Value: item_left
.......... display1..1stringRepresentation defined by the system
Fixed Value: Items left
.......... userSelected0..1booleanIf this coding was chosen directly by the user
......... text0..1stringPlain text representation of the concept
........ allowed[x] 0..1unsignedIntBenefits allowed
...... authorizationRequired 0..1booleanAuthorization required flag
...... authorizationSupporting 0..*CodeableConceptType of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.


...... authorizationUrl 0..1uriPreauthorization requirements endpoint

doco Documentation for this format

This structure is derived from CoverageEligibilityResponse

Summary

Mandatory: 4 elements (18 nested mandatory elements)
Prohibited: 23 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element CoverageEligibilityResponse.identifier is sliced based on the value of value:type.coding.code (Closed)
  • The element CoverageEligibilityResponse.insurance.item is sliced based on the value of value:category.coding.code (Closed)
  • The element CoverageEligibilityResponse.insurance.item.benefit is sliced based on the value of type:allowed[x] (Closed)
  • The element CoverageEligibilityResponse.insurance.item.benefit.allowed[x] is sliced based on the value of type:$this
  • The element CoverageEligibilityResponse.insurance.item.benefit is sliced based on the value of value:type.coding.code (Closed)

Differential View

This structure is derived from CoverageEligibilityResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. CoverageEligibilityResponse 0..*CoverageEligibilityResponseCoverageEligibilityResponse resource
... Slices for identifier 1..1IdentifierBusiness Identifier for coverage eligiblity request
Slice: Unordered, Closed by value:type.coding.code
.... identifier:All Slices Content/Rules for all slices
..... type 1..1CodeableConceptDescription of identifier
...... coding
....... code 0..1codeSymbol in syntax defined by the system
Binding: openIMIS Identifiers Value Set (required)
..... value 1..1stringThe value that is unique
.... identifier:UUID 1..1IdentifierBusiness Identifier for coverage eligiblity request
..... type
...... coding
....... code 1..1codeExternal System generated UUID
Required Pattern: UUID
... status 1..1codeactive | cancelled | draft | entered-in-error
Required Pattern: active
... purpose 1..1codeauth-requirements | benefits | discovery | validation
Required Pattern: benefits
... serviced[x] 0..0
... requestor 0..0
... request 1..1Reference(openIMIS CoverageEligibilityRequest)Eligibility request reference
... outcome 1..1codequeued | complete | error | partial
Required Pattern: complete
... disposition 0..0
... insurer 1..1Reference(openIMIS Insurance Organization)Coverage issuer
.