Universal API Implementation Guide - Local Development build (v1.1.20) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: UAPI CoverageEligibilityResponse

This profile constrains the CoverageEligibilityResponse resource to be used in sharing service request results in UAPI

Usages:

• Use this Profile: UAPI Bundle - Status Update

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gpfShipmentMethod		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Shipment Method URL: https://fhir.developer.gene.com/StructureDefinition/gpf-shipment-method Binding: UAPI Value Set - Shipment Method (required)
extension:statusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (required)
extension:priorAuthTAT		0..1	string	UAPI Prior Auth Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/priorAuthTAT
extension:predAuthTAT		0..1	string	UAPI PreD Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/predAuthTAT
extension:pcpReferralRequired		0..1	string	UAPI PCP Referral Required? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired
extension:preReferralEffectiveDate		0..1	string	UAPI PCP Referral Effective Date URL: https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate
extension:pcpReferralOnFile		0..1	string	UAPI PCP Referral On-file? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile
extension:pcpReferralRecertificationDate		0..1	string	UAPI PCP Referral Recertification Date URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate
extension:spendDownFrequency		0..1	string	UAPI Spend Down Frequency URL: https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency
extension:peerToPeerAvailable		0..1	string	UAPI Peer to Peer Available URL: https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable
extension:noOfAppealsAllowed		0..1	string	UAPI # of Appeals Allowed URL: https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed
extension:appealSubmissionDeadline		0..1	string	UAPI Appeal Submission Deadline URL: https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline
extension:additionalDocumentsRequired		0..1	string	UAPI Additional Documents Required URL: https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired
extension:estimatedAppealTAT		0..1	string	UAPI Estimated Appeal TAT URL: https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT
extension:billingInstructions		0..1	string	UAPI BI - Billing Instructions URL: https://fhir.developer.gene.com/StructureDefinition/billing-instructions
extension:benefitsSummary		0..1	string	UAPI BI - Benefits Summary URL: https://fhir.developer.gene.com/StructureDefinition/benefits-summary
extension:specialtyPharmacy		0..1	CodeableConcept	UAPI BI - Specialty Pharmacy URL: https://fhir.developer.gene.com/StructureDefinition/specialty-pharmacy Binding: UAPI Value Set - Specialty Pharmacy (required)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
purpose	Σ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
created	Σ	1..1	dateTime	Response creation date
request	Σ	1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference
outcome	Σ	1..1	code	queued | complete | error | partial Binding: RemittanceOutcome (required): The outcome of the processing.
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
insurance		0..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
coverage	Σ	1..1	Reference(Coverage)	Insurance information
item	C	0..*	BackboneElement	Benefits and authorization details Constraints: ces-1
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService	S	0..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:productService	Σ	1..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product Service (required)
coding:jcode	Σ	0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product JCode (required)
coding:preDetermination	Σ	0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - PreDetermination (required)
benefit		0..*	BackboneElement	Benefit Summary
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
authorizationSupporting	S	0..1	CodeableConcept	Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.outcome	required	RemittanceOutcome http://hl7.org/fhir/ValueSet/remittance-outcome|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrService.coding:productService	required	UapiValueSetProductService(a valid code from UAPI Code System - Product/Service) https://fhir.developer.gene.com/ValueSet/uapi-prod-service From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:jcode	required	UapiValueSetProductJCode(a valid code from UAPI Code System - Product JCode) https://fhir.developer.gene.com/ValueSet/uapi-product-jcode From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:preDetermination	required	UapiValueSetPreDetermination(a valid code from UAPI Code System - PreDetermination) https://fhir.developer.gene.com/ValueSet/uapi-pre-determination From this IG
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type From the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
ces-1	error	CoverageEligibilityResponse.insurance.item	SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists()
dom-2	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where(((id.exists() and ('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url)))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from CoverageEligibilityResponse

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CoverageEligibilityResponse			CoverageEligibilityResponse
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gpfShipmentMethod		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Shipment Method URL: https://fhir.developer.gene.com/StructureDefinition/gpf-shipment-method Binding: UAPI Value Set - Shipment Method (required)
extension:statusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (required)
extension:priorAuthTAT		0..1	string	UAPI Prior Auth Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/priorAuthTAT
extension:predAuthTAT		0..1	string	UAPI PreD Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/predAuthTAT
extension:pcpReferralRequired		0..1	string	UAPI PCP Referral Required? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired
extension:preReferralEffectiveDate		0..1	string	UAPI PCP Referral Effective Date URL: https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate
extension:pcpReferralOnFile		0..1	string	UAPI PCP Referral On-file? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile
extension:pcpReferralRecertificationDate		0..1	string	UAPI PCP Referral Recertification Date URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate
extension:spendDownFrequency		0..1	string	UAPI Spend Down Frequency URL: https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency
extension:peerToPeerAvailable		0..1	string	UAPI Peer to Peer Available URL: https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable
extension:noOfAppealsAllowed		0..1	string	UAPI # of Appeals Allowed URL: https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed
extension:appealSubmissionDeadline		0..1	string	UAPI Appeal Submission Deadline URL: https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline
extension:additionalDocumentsRequired		0..1	string	UAPI Additional Documents Required URL: https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired
extension:estimatedAppealTAT		0..1	string	UAPI Estimated Appeal TAT URL: https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT
extension:billingInstructions		0..1	string	UAPI BI - Billing Instructions URL: https://fhir.developer.gene.com/StructureDefinition/billing-instructions
extension:benefitsSummary		0..1	string	UAPI BI - Benefits Summary URL: https://fhir.developer.gene.com/StructureDefinition/benefits-summary
extension:specialtyPharmacy		0..1	CodeableConcept	UAPI BI - Specialty Pharmacy URL: https://fhir.developer.gene.com/StructureDefinition/specialty-pharmacy Binding: UAPI Value Set - Specialty Pharmacy (required)
insurance
item
productOrService	S	0..1	CodeableConcept	Billing, service, product, or drug code
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:productService		1..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product Service (required)
coding:jcode		0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product JCode (required)
coding:preDetermination		0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - PreDetermination (required)
benefit
type	S	1..1	CodeableConcept	Benefit classification
coding
system		1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type
code		1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Benefit Type (required)
authorizationSupporting	S	0..1	CodeableConcept	Type of required supporting materials
coding
system		1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-authorization-supporting
code		1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Product Authorization (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.insurance.item.productOrService.coding:productService	required	UapiValueSetProductService(a valid code from UAPI Code System - Product/Service) https://fhir.developer.gene.com/ValueSet/uapi-prod-service From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:jcode	required	UapiValueSetProductJCode(a valid code from UAPI Code System - Product JCode) https://fhir.developer.gene.com/ValueSet/uapi-product-jcode From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:preDetermination	required	UapiValueSetPreDetermination(a valid code from UAPI Code System - PreDetermination) https://fhir.developer.gene.com/ValueSet/uapi-pre-determination From this IG
CoverageEligibilityResponse.insurance.item.benefit.type.coding.code	required	UapiValueSetBenefitType(a valid code from UAPI Code System - Benefit Type) https://fhir.developer.gene.com/ValueSet/uapi-benefit-type From this IG
CoverageEligibilityResponse.insurance.item.authorizationSupporting.coding.code	required	UapiValueSetAuthorizationSupporting(a valid code from UAPI Code System - Authorization-Supporting Documents Submission) https://fhir.developer.gene.com/ValueSet/uapi-authorization-supporting From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse resource
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): IETF language tag Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources Constraints: dom-r4b
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gpfShipmentMethod		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Shipment Method URL: https://fhir.developer.gene.com/StructureDefinition/gpf-shipment-method Binding: UAPI Value Set - Shipment Method (required)
extension:statusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (required)
extension:priorAuthTAT		0..1	string	UAPI Prior Auth Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/priorAuthTAT
extension:predAuthTAT		0..1	string	UAPI PreD Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/predAuthTAT
extension:pcpReferralRequired		0..1	string	UAPI PCP Referral Required? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired
extension:preReferralEffectiveDate		0..1	string	UAPI PCP Referral Effective Date URL: https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate
extension:pcpReferralOnFile		0..1	string	UAPI PCP Referral On-file? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile
extension:pcpReferralRecertificationDate		0..1	string	UAPI PCP Referral Recertification Date URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate
extension:spendDownFrequency		0..1	string	UAPI Spend Down Frequency URL: https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency
extension:peerToPeerAvailable		0..1	string	UAPI Peer to Peer Available URL: https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable
extension:noOfAppealsAllowed		0..1	string	UAPI # of Appeals Allowed URL: https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed
extension:appealSubmissionDeadline		0..1	string	UAPI Appeal Submission Deadline URL: https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline
extension:additionalDocumentsRequired		0..1	string	UAPI Additional Documents Required URL: https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired
extension:estimatedAppealTAT		0..1	string	UAPI Estimated Appeal TAT URL: https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT
extension:billingInstructions		0..1	string	UAPI BI - Billing Instructions URL: https://fhir.developer.gene.com/StructureDefinition/billing-instructions
extension:benefitsSummary		0..1	string	UAPI BI - Benefits Summary URL: https://fhir.developer.gene.com/StructureDefinition/benefits-summary
extension:specialtyPharmacy		0..1	CodeableConcept	UAPI BI - Specialty Pharmacy URL: https://fhir.developer.gene.com/StructureDefinition/specialty-pharmacy Binding: UAPI Value Set - Specialty Pharmacy (required)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for coverage eligiblity request
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
purpose	Σ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
serviced[x]		0..1		Estimated date or dates of service
servicedDate			date
servicedPeriod			Period
created	Σ	1..1	dateTime	Response creation date
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
request	Σ	1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference
outcome	Σ	1..1	code	queued | complete | error | partial Binding: RemittanceOutcome (required): The outcome of the processing.
disposition		0..1	string	Disposition Message
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
coverage	Σ	1..1	Reference(Coverage)	Insurance information
inforce		0..1	boolean	Coverage inforce indicator
benefitPeriod		0..1	Period	When the benefits are applicable
item	C	0..*	BackboneElement	Benefits and authorization details Constraints: ces-1
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.
productOrService	S	0..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:productService	Σ	1..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product Service (required)
coding:jcode	Σ	0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product JCode (required)
coding:preDetermination	Σ	0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - PreDetermination (required)
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Product 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..1	Reference(Practitioner | PractitionerRole)	Performing practitioner
excluded		0..1	boolean	Excluded from the plan
name		0..1	string	Short name for the benefit
description		0..1	string	Description of the benefit or services covered
network		0..1	CodeableConcept	In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
benefit		0..*	BackboneElement	Benefit Summary
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Benefit Type (required)
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
allowed[x]		0..1		Benefits allowed
allowedUnsignedInt			unsignedInt
allowedString			string
allowedMoney			Money
used[x]		0..1		Benefits used
usedUnsignedInt			unsignedInt
usedString			string
usedMoney			Money
authorizationRequired		0..1	boolean	Authorization required flag
authorizationSupporting	S	0..1	CodeableConcept	Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-authorization-supporting
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Product Authorization (required)
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
authorizationUrl		0..1	uri	Preauthorization requirements endpoint
preAuthRef		0..1	string	Preauthorization reference
form		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
error		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.outcome	required	RemittanceOutcome http://hl7.org/fhir/ValueSet/remittance-outcome|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrService.coding:productService	required	UapiValueSetProductService(a valid code from UAPI Code System - Product/Service) https://fhir.developer.gene.com/ValueSet/uapi-prod-service From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:jcode	required	UapiValueSetProductJCode(a valid code from UAPI Code System - Product JCode) https://fhir.developer.gene.com/ValueSet/uapi-product-jcode From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:preDetermination	required	UapiValueSetPreDetermination(a valid code from UAPI Code System - PreDetermination) https://fhir.developer.gene.com/ValueSet/uapi-pre-determination From this IG
CoverageEligibilityResponse.insurance.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
CoverageEligibilityResponse.insurance.item.network	example	NetworkTypeCodes http://hl7.org/fhir/ValueSet/benefit-network From the FHIR Standard
CoverageEligibilityResponse.insurance.item.unit	example	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard
CoverageEligibilityResponse.insurance.item.term	example	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type From the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.type.coding.code	required	UapiValueSetBenefitType(a valid code from UAPI Code System - Benefit Type) https://fhir.developer.gene.com/ValueSet/uapi-benefit-type From this IG
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support From the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupporting.coding.code	required	UapiValueSetAuthorizationSupporting(a valid code from UAPI Code System - Authorization-Supporting Documents Submission) https://fhir.developer.gene.com/ValueSet/uapi-authorization-supporting From this IG
CoverageEligibilityResponse.form	example	Form Codes http://hl7.org/fhir/ValueSet/forms From the FHIR Standard
CoverageEligibilityResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
ces-1	error	CoverageEligibilityResponse.insurance.item	SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists()
dom-2	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where(((id.exists() and ('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url)))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityResponse	A resource should have narrative for robust management : text.`div`.exists()
dom-r4b	warning	CoverageEligibilityResponse.contained	Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems : ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from CoverageEligibilityResponse

Summary

Mandatory: 0 element(6 nested mandatory elements)
Must-Support: 3 elements

Extensions

This structure refers to these extensions:

• https://fhir.developer.gene.com/StructureDefinition/gpf-shipment-method
• https://fhir.developer.gene.com/StructureDefinition/statusOutcome
• https://fhir.developer.gene.com/StructureDefinition/priorAuthTAT
• https://fhir.developer.gene.com/StructureDefinition/predAuthTAT
• https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired
• https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate
• https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile
• https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate
• https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency
• https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable
• https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed
• https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline
• https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired
• https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT
• https://fhir.developer.gene.com/StructureDefinition/billing-instructions
• https://fhir.developer.gene.com/StructureDefinition/benefits-summary
• https://fhir.developer.gene.com/StructureDefinition/specialty-pharmacy

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of CoverageEligibilityResponse.insurance.item.productOrService.coding (Closed)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gpfShipmentMethod		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Shipment Method URL: https://fhir.developer.gene.com/StructureDefinition/gpf-shipment-method Binding: UAPI Value Set - Shipment Method (required)
extension:statusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (required)
extension:priorAuthTAT		0..1	string	UAPI Prior Auth Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/priorAuthTAT
extension:predAuthTAT		0..1	string	UAPI PreD Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/predAuthTAT
extension:pcpReferralRequired		0..1	string	UAPI PCP Referral Required? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired
extension:preReferralEffectiveDate		0..1	string	UAPI PCP Referral Effective Date URL: https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate
extension:pcpReferralOnFile		0..1	string	UAPI PCP Referral On-file? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile
extension:pcpReferralRecertificationDate		0..1	string	UAPI PCP Referral Recertification Date URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate
extension:spendDownFrequency		0..1	string	UAPI Spend Down Frequency URL: https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency
extension:peerToPeerAvailable		0..1	string	UAPI Peer to Peer Available URL: https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable
extension:noOfAppealsAllowed		0..1	string	UAPI # of Appeals Allowed URL: https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed
extension:appealSubmissionDeadline		0..1	string	UAPI Appeal Submission Deadline URL: https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline
extension:additionalDocumentsRequired		0..1	string	UAPI Additional Documents Required URL: https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired
extension:estimatedAppealTAT		0..1	string	UAPI Estimated Appeal TAT URL: https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT
extension:billingInstructions		0..1	string	UAPI BI - Billing Instructions URL: https://fhir.developer.gene.com/StructureDefinition/billing-instructions
extension:benefitsSummary		0..1	string	UAPI BI - Benefits Summary URL: https://fhir.developer.gene.com/StructureDefinition/benefits-summary
extension:specialtyPharmacy		0..1	CodeableConcept	UAPI BI - Specialty Pharmacy URL: https://fhir.developer.gene.com/StructureDefinition/specialty-pharmacy Binding: UAPI Value Set - Specialty Pharmacy (required)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
purpose	Σ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
created	Σ	1..1	dateTime	Response creation date
request	Σ	1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference
outcome	Σ	1..1	code	queued | complete | error | partial Binding: RemittanceOutcome (required): The outcome of the processing.
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
insurance		0..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
coverage	Σ	1..1	Reference(Coverage)	Insurance information
item	C	0..*	BackboneElement	Benefits and authorization details Constraints: ces-1
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService	S	0..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:productService	Σ	1..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product Service (required)
coding:jcode	Σ	0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product JCode (required)
coding:preDetermination	Σ	0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - PreDetermination (required)
benefit		0..*	BackboneElement	Benefit Summary
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
authorizationSupporting	S	0..1	CodeableConcept	Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.outcome	required	RemittanceOutcome http://hl7.org/fhir/ValueSet/remittance-outcome|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrService.coding:productService	required	UapiValueSetProductService(a valid code from UAPI Code System - Product/Service) https://fhir.developer.gene.com/ValueSet/uapi-prod-service From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:jcode	required	UapiValueSetProductJCode(a valid code from UAPI Code System - Product JCode) https://fhir.developer.gene.com/ValueSet/uapi-product-jcode From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:preDetermination	required	UapiValueSetPreDetermination(a valid code from UAPI Code System - PreDetermination) https://fhir.developer.gene.com/ValueSet/uapi-pre-determination From this IG
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type From the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
ces-1	error	CoverageEligibilityResponse.insurance.item	SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists()
dom-2	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where(((id.exists() and ('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url)))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from CoverageEligibilityResponse

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CoverageEligibilityResponse			CoverageEligibilityResponse
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gpfShipmentMethod		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Shipment Method URL: https://fhir.developer.gene.com/StructureDefinition/gpf-shipment-method Binding: UAPI Value Set - Shipment Method (required)
extension:statusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (required)
extension:priorAuthTAT		0..1	string	UAPI Prior Auth Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/priorAuthTAT
extension:predAuthTAT		0..1	string	UAPI PreD Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/predAuthTAT
extension:pcpReferralRequired		0..1	string	UAPI PCP Referral Required? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired
extension:preReferralEffectiveDate		0..1	string	UAPI PCP Referral Effective Date URL: https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate
extension:pcpReferralOnFile		0..1	string	UAPI PCP Referral On-file? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile
extension:pcpReferralRecertificationDate		0..1	string	UAPI PCP Referral Recertification Date URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate
extension:spendDownFrequency		0..1	string	UAPI Spend Down Frequency URL: https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency
extension:peerToPeerAvailable		0..1	string	UAPI Peer to Peer Available URL: https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable
extension:noOfAppealsAllowed		0..1	string	UAPI # of Appeals Allowed URL: https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed
extension:appealSubmissionDeadline		0..1	string	UAPI Appeal Submission Deadline URL: https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline
extension:additionalDocumentsRequired		0..1	string	UAPI Additional Documents Required URL: https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired
extension:estimatedAppealTAT		0..1	string	UAPI Estimated Appeal TAT URL: https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT
extension:billingInstructions		0..1	string	UAPI BI - Billing Instructions URL: https://fhir.developer.gene.com/StructureDefinition/billing-instructions
extension:benefitsSummary		0..1	string	UAPI BI - Benefits Summary URL: https://fhir.developer.gene.com/StructureDefinition/benefits-summary
extension:specialtyPharmacy		0..1	CodeableConcept	UAPI BI - Specialty Pharmacy URL: https://fhir.developer.gene.com/StructureDefinition/specialty-pharmacy Binding: UAPI Value Set - Specialty Pharmacy (required)
insurance
item
productOrService	S	0..1	CodeableConcept	Billing, service, product, or drug code
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:productService		1..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product Service (required)
coding:jcode		0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product JCode (required)
coding:preDetermination		0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - PreDetermination (required)
benefit
type	S	1..1	CodeableConcept	Benefit classification
coding
system		1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type
code		1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Benefit Type (required)
authorizationSupporting	S	0..1	CodeableConcept	Type of required supporting materials
coding
system		1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-authorization-supporting
code		1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Product Authorization (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.insurance.item.productOrService.coding:productService	required	UapiValueSetProductService(a valid code from UAPI Code System - Product/Service) https://fhir.developer.gene.com/ValueSet/uapi-prod-service From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:jcode	required	UapiValueSetProductJCode(a valid code from UAPI Code System - Product JCode) https://fhir.developer.gene.com/ValueSet/uapi-product-jcode From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:preDetermination	required	UapiValueSetPreDetermination(a valid code from UAPI Code System - PreDetermination) https://fhir.developer.gene.com/ValueSet/uapi-pre-determination From this IG
CoverageEligibilityResponse.insurance.item.benefit.type.coding.code	required	UapiValueSetBenefitType(a valid code from UAPI Code System - Benefit Type) https://fhir.developer.gene.com/ValueSet/uapi-benefit-type From this IG
CoverageEligibilityResponse.insurance.item.authorizationSupporting.coding.code	required	UapiValueSetAuthorizationSupporting(a valid code from UAPI Code System - Authorization-Supporting Documents Submission) https://fhir.developer.gene.com/ValueSet/uapi-authorization-supporting From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse resource
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): IETF language tag Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources Constraints: dom-r4b
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:gpfShipmentMethod		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Shipment Method URL: https://fhir.developer.gene.com/StructureDefinition/gpf-shipment-method Binding: UAPI Value Set - Shipment Method (required)
extension:statusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (required)
extension:priorAuthTAT		0..1	string	UAPI Prior Auth Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/priorAuthTAT
extension:predAuthTAT		0..1	string	UAPI PreD Est. TAT URL: https://fhir.developer.gene.com/StructureDefinition/predAuthTAT
extension:pcpReferralRequired		0..1	string	UAPI PCP Referral Required? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired
extension:preReferralEffectiveDate		0..1	string	UAPI PCP Referral Effective Date URL: https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate
extension:pcpReferralOnFile		0..1	string	UAPI PCP Referral On-file? URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile
extension:pcpReferralRecertificationDate		0..1	string	UAPI PCP Referral Recertification Date URL: https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate
extension:spendDownFrequency		0..1	string	UAPI Spend Down Frequency URL: https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency
extension:peerToPeerAvailable		0..1	string	UAPI Peer to Peer Available URL: https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable
extension:noOfAppealsAllowed		0..1	string	UAPI # of Appeals Allowed URL: https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed
extension:appealSubmissionDeadline		0..1	string	UAPI Appeal Submission Deadline URL: https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline
extension:additionalDocumentsRequired		0..1	string	UAPI Additional Documents Required URL: https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired
extension:estimatedAppealTAT		0..1	string	UAPI Estimated Appeal TAT URL: https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT
extension:billingInstructions		0..1	string	UAPI BI - Billing Instructions URL: https://fhir.developer.gene.com/StructureDefinition/billing-instructions
extension:benefitsSummary		0..1	string	UAPI BI - Benefits Summary URL: https://fhir.developer.gene.com/StructureDefinition/benefits-summary
extension:specialtyPharmacy		0..1	CodeableConcept	UAPI BI - Specialty Pharmacy URL: https://fhir.developer.gene.com/StructureDefinition/specialty-pharmacy Binding: UAPI Value Set - Specialty Pharmacy (required)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for coverage eligiblity request
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
purpose	Σ	1..*	code	auth-requirements | benefits | discovery | validation Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
patient	Σ	1..1	Reference(Patient)	Intended recipient of products and services
serviced[x]		0..1		Estimated date or dates of service
servicedDate			date
servicedPeriod			Period
created	Σ	1..1	dateTime	Response creation date
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the request
request	Σ	1..1	Reference(CoverageEligibilityRequest)	Eligibility request reference
outcome	Σ	1..1	code	queued | complete | error | partial Binding: RemittanceOutcome (required): The outcome of the processing.
disposition		0..1	string	Disposition Message
insurer	Σ	1..1	Reference(Organization)	Coverage issuer
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
coverage	Σ	1..1	Reference(Coverage)	Insurance information
inforce		0..1	boolean	Coverage inforce indicator
benefitPeriod		0..1	Period	When the benefits are applicable
item	C	0..*	BackboneElement	Benefits and authorization details Constraints: ces-1
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.
productOrService	S	0..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:productService	Σ	1..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product Service (required)
coding:jcode	Σ	0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - Product JCode (required)
coding:preDetermination	Σ	0..1	Coding	Code defined by a terminology system Binding: UAPI Value Set - PreDetermination (required)
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Product 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..1	Reference(Practitioner | PractitionerRole)	Performing practitioner
excluded		0..1	boolean	Excluded from the plan
name		0..1	string	Short name for the benefit
description		0..1	string	Description of the benefit or services covered
network		0..1	CodeableConcept	In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
benefit		0..*	BackboneElement	Benefit Summary
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Benefit Type (required)
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
allowed[x]		0..1		Benefits allowed
allowedUnsignedInt			unsignedInt
allowedString			string
allowedMoney			Money
used[x]		0..1		Benefits used
usedUnsignedInt			unsignedInt
usedString			string
usedMoney			Money
authorizationRequired		0..1	boolean	Authorization required flag
authorizationSupporting	S	0..1	CodeableConcept	Type of required supporting materials Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-authorization-supporting
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Product Authorization (required)
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
authorizationUrl		0..1	uri	Preauthorization requirements endpoint
preAuthRef		0..1	string	Preauthorization reference
form		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
error		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The error codes for adjudication processing.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
CoverageEligibilityResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose http://hl7.org/fhir/ValueSet/eligibilityresponse-purpose|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.outcome	required	RemittanceOutcome http://hl7.org/fhir/ValueSet/remittance-outcome|4.3.0 From the FHIR Standard
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
CoverageEligibilityResponse.insurance.item.productOrService.coding:productService	required	UapiValueSetProductService(a valid code from UAPI Code System - Product/Service) https://fhir.developer.gene.com/ValueSet/uapi-prod-service From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:jcode	required	UapiValueSetProductJCode(a valid code from UAPI Code System - Product JCode) https://fhir.developer.gene.com/ValueSet/uapi-product-jcode From this IG
CoverageEligibilityResponse.insurance.item.productOrService.coding:preDetermination	required	UapiValueSetPreDetermination(a valid code from UAPI Code System - PreDetermination) https://fhir.developer.gene.com/ValueSet/uapi-pre-determination From this IG
CoverageEligibilityResponse.insurance.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
CoverageEligibilityResponse.insurance.item.network	example	NetworkTypeCodes http://hl7.org/fhir/ValueSet/benefit-network From the FHIR Standard
CoverageEligibilityResponse.insurance.item.unit	example	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard
CoverageEligibilityResponse.insurance.item.term	example	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type From the FHIR Standard
CoverageEligibilityResponse.insurance.item.benefit.type.coding.code	required	UapiValueSetBenefitType(a valid code from UAPI Code System - Benefit Type) https://fhir.developer.gene.com/ValueSet/uapi-benefit-type From this IG
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes http://hl7.org/fhir/ValueSet/coverageeligibilityresponse-ex-auth-support From the FHIR Standard
CoverageEligibilityResponse.insurance.item.authorizationSupporting.coding.code	required	UapiValueSetAuthorizationSupporting(a valid code from UAPI Code System - Authorization-Supporting Documents Submission) https://fhir.developer.gene.com/ValueSet/uapi-authorization-supporting From this IG
CoverageEligibilityResponse.form	example	Form Codes http://hl7.org/fhir/ValueSet/forms From the FHIR Standard
CoverageEligibilityResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
ces-1	error	CoverageEligibilityResponse.insurance.item	SHALL contain a category or a billcode but not both. : category.exists() xor productOrService.exists()
dom-2	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CoverageEligibilityResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where(((id.exists() and ('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url)))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CoverageEligibilityResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CoverageEligibilityResponse	A resource should have narrative for robust management : text.`div`.exists()
dom-r4b	warning	CoverageEligibilityResponse.contained	Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems : ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from CoverageEligibilityResponse

Summary

Mandatory: 0 element(6 nested mandatory elements)
Must-Support: 3 elements

Extensions

This structure refers to these extensions:

• https://fhir.developer.gene.com/StructureDefinition/gpf-shipment-method
• https://fhir.developer.gene.com/StructureDefinition/statusOutcome
• https://fhir.developer.gene.com/StructureDefinition/priorAuthTAT
• https://fhir.developer.gene.com/StructureDefinition/predAuthTAT
• https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired
• https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate
• https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile
• https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate
• https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency
• https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable
• https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed
• https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline
• https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired
• https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT
• https://fhir.developer.gene.com/StructureDefinition/billing-instructions
• https://fhir.developer.gene.com/StructureDefinition/benefits-summary
• https://fhir.developer.gene.com/StructureDefinition/specialty-pharmacy

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of CoverageEligibilityResponse.insurance.item.productOrService.coding (Closed)