Universal API Implementation Guide - Local Development build (v1.1.19). See the Directory of published versions

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Resource Profile: UAPI CoverageEligibilityResponse

Official URL: https://fhir.developer.gene.com/StructureDefinition/uapi-coverage-eligibility-response				Version: 1.1.19
Active as of 2020-12-11		Responsible: Genentech USIX PE	Realm:	Computable Name: UapiCoverageEligibilityResponse

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

Usage:

• Use this Resource Profile: UAPI Bundle - Status Update

Formal Views of Profile Content

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

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

This structure is derived from CoverageEligibilityResponse

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse resource
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
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)
StatusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (required)
insurance
item
productOrService	S	0..1	CodeableConcept	Billing, service, product, or drug code
coding
system		1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service
code		1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Product Service (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
CoverageEligibilityResponse.insurance.item.productOrService.coding.code	required	UapiValueSetProductService (a valid code from UAPI Code System - Product/Service)
CoverageEligibilityResponse.insurance.item.benefit.type.coding.code	required	UapiValueSetBenefitType (a valid code from UAPI Code System - Benefit Type)
CoverageEligibilityResponse.insurance.item.authorizationSupporting.coding.code	required	UapiValueSetAuthorizationSupporting (a valid code from UAPI Code System - Authorization-Supporting Documents Submission)

Name	Flags	Card.	Type	Description & Constraints
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
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)
StatusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (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
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.
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
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose
CoverageEligibilityResponse.outcome	required	RemittanceOutcome
CoverageEligibilityResponse.insurance.item.productOrService	example	USCLSCodes
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes

Name	Flags	Card.	Type	Description & Constraints
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
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
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)
StatusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (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
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
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-product-service
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 Service (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
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
CoverageEligibilityResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose
CoverageEligibilityResponse.outcome	required	RemittanceOutcome
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategoryCodes
CoverageEligibilityResponse.insurance.item.productOrService	example	USCLSCodes
CoverageEligibilityResponse.insurance.item.productOrService.coding.code	required	UapiValueSetProductService (a valid code from UAPI Code System - Product/Service)
CoverageEligibilityResponse.insurance.item.modifier	example	ModifierTypeCodes
CoverageEligibilityResponse.insurance.item.network	example	NetworkTypeCodes
CoverageEligibilityResponse.insurance.item.unit	example	UnitTypeCodes
CoverageEligibilityResponse.insurance.item.term	example	BenefitTermCodes
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes
CoverageEligibilityResponse.insurance.item.benefit.type.coding.code	required	UapiValueSetBenefitType (a valid code from UAPI Code System - Benefit Type)
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes
CoverageEligibilityResponse.insurance.item.authorizationSupporting.coding.code	required	UapiValueSetAuthorizationSupporting (a valid code from UAPI Code System - Authorization-Supporting Documents Submission)
CoverageEligibilityResponse.form	example	Form Codes
CoverageEligibilityResponse.error.code	example	Adjudication Error Codes

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

Differential View

This structure is derived from CoverageEligibilityResponse

Name	Flags	Card.	Type	Description & Constraints
CoverageEligibilityResponse		0..*	CoverageEligibilityResponse	CoverageEligibilityResponse resource
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
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)
StatusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (required)
insurance
item
productOrService	S	0..1	CodeableConcept	Billing, service, product, or drug code
coding
system		1..1	uri	Identity of the terminology system Required Pattern: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service
code		1..1	code	Symbol in syntax defined by the system Binding: UAPI Value Set - Product Service (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
CoverageEligibilityResponse.insurance.item.productOrService.coding.code	required	UapiValueSetProductService (a valid code from UAPI Code System - Product/Service)
CoverageEligibilityResponse.insurance.item.benefit.type.coding.code	required	UapiValueSetBenefitType (a valid code from UAPI Code System - Benefit Type)
CoverageEligibilityResponse.insurance.item.authorizationSupporting.coding.code	required	UapiValueSetAuthorizationSupporting (a valid code from UAPI Code System - Authorization-Supporting Documents Submission)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
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
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)
StatusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (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
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.
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
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose
CoverageEligibilityResponse.outcome	required	RemittanceOutcome
CoverageEligibilityResponse.insurance.item.productOrService	example	USCLSCodes
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
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
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
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)
StatusOutcome		0..1	CodeableConcept	UAPI CoverageEligibilityResponse Status URL: https://fhir.developer.gene.com/StructureDefinition/statusOutcome Binding: UAPI Value Set - Coverage Outcome (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
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
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-product-service
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 Service (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
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
CoverageEligibilityResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
CoverageEligibilityResponse.status	required	FinancialResourceStatusCodes
CoverageEligibilityResponse.purpose	required	EligibilityResponsePurpose
CoverageEligibilityResponse.outcome	required	RemittanceOutcome
CoverageEligibilityResponse.insurance.item.category	example	BenefitCategoryCodes
CoverageEligibilityResponse.insurance.item.productOrService	example	USCLSCodes
CoverageEligibilityResponse.insurance.item.productOrService.coding.code	required	UapiValueSetProductService (a valid code from UAPI Code System - Product/Service)
CoverageEligibilityResponse.insurance.item.modifier	example	ModifierTypeCodes
CoverageEligibilityResponse.insurance.item.network	example	NetworkTypeCodes
CoverageEligibilityResponse.insurance.item.unit	example	UnitTypeCodes
CoverageEligibilityResponse.insurance.item.term	example	BenefitTermCodes
CoverageEligibilityResponse.insurance.item.benefit.type	example	BenefitTypeCodes
CoverageEligibilityResponse.insurance.item.benefit.type.coding.code	required	UapiValueSetBenefitType (a valid code from UAPI Code System - Benefit Type)
CoverageEligibilityResponse.insurance.item.authorizationSupporting	example	CoverageEligibilityResponseAuthSupportCodes
CoverageEligibilityResponse.insurance.item.authorizationSupporting.coding.code	required	UapiValueSetAuthorizationSupporting (a valid code from UAPI Code System - Authorization-Supporting Documents Submission)
CoverageEligibilityResponse.form	example	Form Codes
CoverageEligibilityResponse.error.code	example	Adjudication Error Codes

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

Other representations of profile: CSV, Excel, Schematron