CoverageEligibilityRequest

Overview

The CoverageEligibilityRequest API empowers healthcare developers to efficiently request and receive information on patients' insurance coverage eligibility, facilitating real-time verification processes during clinical workflows. By integrating this API, developers can enhance the accuracy and speed of eligibility inquiries, optimize patient care coordination, and ensure seamless communication with insurance providers within healthcare applications.

Use Cases

Eligibility Checks - Submit electronic eligibility check requests to payers for status.
Referral Management - Check coverage for referral requests to in-network specialists/facilities.
Patient Estimates - Request eligibility details needed to provide estimates for out-of-pocket costs.
Claims Processing - Verify active coverage before batch claim file submissions.
Benefits coordination - Assess coordination across patient’s multiple coverages.
Premium Reminders - Trigger eligibility checks that prompt patients about unpaid premiums.
Patient Portals - Enable self-service eligibility checks via patient portal interfaces.
New Patient Workflows - Perform eligibility check during patient first encounter workflows.
Utilization Reviews - Analyze eligibility check requests frequency and patterns.
Patient Engagement - Use eligibility status to drive patient outreach for care coordination.

EHR Data Model

EHR	Supported?	Mapped Source Object
Athena	✅
Elation	✅
Epic	✅

Object Definition

{
  "resourceType": "CoverageEligibilityRequest",
  "id": "52345",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the CoverageEligibilityRequest</div>"
  },
  "identifier": [
    {
      "system": "http://happyvalley.com/coverageelegibilityrequest",
      "value": "52345"
    }
  ],
  "status": "active",
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "purpose": [
    "validation"
  ],
  "patient": {
    "reference": "Patient/pat1"
  },
  "created": "2014-08-16",
  "provider": {
    "reference": "Organization/1"
  },
  "insurer": {
    "reference": "Organization/2"
  },
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}

Data Fields

Data Field	Type	Description
resourceType	CoverageEligibilityRequest	This is a CoverageEligibilityRequest resource
id	id	The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
meta	Meta	The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules	uri	A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
language	code	The base language in which the resource is written.
text	Narrative	A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
contained	BackboneElement	These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
extension	Extension	May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
identifier	Identifier	A unique identifier assigned to this coverage eligiblity request.
status	code	The status of the resource instance.
priority	CodeableConcept	When the requestor expects the processor to complete processing.
purpose	code	Code to specify whether requesting: prior authorization requirements for some service categories or billing codes; benefits for coverages specified or discovered; discovery and return of coverages for the patient; and/or validation that the specified coverage is in-force at the date/period specified or 'now' if not specified.
patient	Reference	The party who is the beneficiary of the supplied coverage and for whom eligibility is sought.
servicedDate	string	The date or dates when the enclosed suite of services were performed or completed.
servicedPeriod	Period	The date or dates when the enclosed suite of services were performed or completed.
created	dateTime	The date when this resource was created.
enterer	Reference	Person who created the request.
provider	Reference	The provider which is responsible for the request.
insurer	Reference	The Insurer who issued the coverage in question and is the recipient of the request.
facility	Reference	Facility where the services are intended to be provided.
supportingInfo	BackboneElement	Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
supportingInfo.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
supportingInfo.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
supportingInfo.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
supportingInfo.sequence	positiveInt	A number to uniquely identify supporting information entries.
supportingInfo.information	Reference	Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
supportingInfo.appliesToAll	boolean	The supporting materials are applicable for all detail items, product/servce categories and specific billing codes.
insurance	BackboneElement	Financial instruments for reimbursement for the health care products and services.
insurance.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
insurance.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
insurance.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
insurance.focal	boolean	A flag to indicate that this Coverage is to be used for evaluation of this request when set to true.
insurance.coverage	Reference	Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
insurance.businessArrangement	string	A business agreement number established between the provider and the insurer for special business processing purposes.
item	BackboneElement	Service categories or billable services for which benefit details and/or an authorization prior to service delivery may be required by the payor.
item.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
item.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
item.supportingInfoSequence	positiveInt	Exceptions, special conditions and supporting information applicable for this service or product line.
item.category	CodeableConcept	Code to identify the general type of benefits under which products and services are provided.
item.productOrService	CodeableConcept	This contains the product, service, drug or other billing code for the item.
item.modifier	CodeableConcept	Item typification or modifiers codes to convey additional context for the product or service.
item.provider	Reference	The practitioner who is responsible for the product or service to be rendered to the patient.
item.quantity	Quantity	The number of repetitions of a service or product.
item.unitPrice	Money	The amount charged to the patient by the provider for a single unit.
item.facility	Reference	Facility where the services will be provided.
item.diagnosis	BackboneElement	Patient diagnosis for which care is sought.
item.diagnosis.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.diagnosis.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
item.diagnosis.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
item.diagnosis.diagnosisCodeableConcept	CodeableConcept	The nature of illness or problem in a coded form or as a reference to an external defined Condition.
item.diagnosis.diagnosisReference	Reference	The nature of illness or problem in a coded form or as a reference to an external defined Condition.
item.detail	Reference	The plan/proposal/order describing the proposed service in detail.

Extensions

Name	URL

Operations & APIs

Goal: to show the diff type of operations that are supported. Link each operation that goes into the API level

CoverageEligibilityRequest

Overview

Use Cases

EHR Data Model

Object Definition

Data Fields

Extensions

Operations & APIs

CoverageEligibilityRequest-GET

CoverageEligibilityRequest-POST

CoverageEligibilityRequest ID-GET

CoverageEligibilityRequest ID-PUT

CoverageEligibilityRequest ID-DELETE