CoverageEligibilityResponse

Overview

The CoverageEligibilityResponse API empowers healthcare developers to seamlessly access and interpret insurance coverage eligibility information, enabling real-time verification and validation during clinical workflows. By integrating this API, developers can enhance the efficiency of patient coverage checks, optimize billing processes, and ensure accurate financial transactions within healthcare applications.

Use Cases

Claim Authorization - Check if planned services meet authorization requirements for processing claims.
Referral Management - Verify coverage for referral requests to in-network specialists and facilities.
Patient Pay Estimates - Analyze response data to provide estimates of out-of-pocket costs.
Formulary Checks - Check eligibility responses for covered prescription medications and plans.
Coordination of Benefits - Assess coordination across multiple coverages based on eligibility details.
Premium Changes - Notify patients who lose active eligibility due to non-payment of premiums.
Product Bundling - Use eligibility data to recommend additional coverage products to patients.
Utilization Reviews - Perform periodic utilization reviews on eligibility check frequency.
Patient Engagement - Use eligibility status to drive patient outreach for care coordination.

EHR Data Model

EHR	Supported?	Mapped Source Object
Athena	✅	Insurance Benefit Details
Elation	✅	Insurance Eligibility
Epic	✅	N/A

Object Definition

{
  "resourceType": "CoverageEligibilityResponse",
  "id": "E2500",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the CoverageEligibilityResponse.</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/coverageeligibilityresponse",
      "value": "881234"
    }
  ],
  "status": "active",
  "purpose": [
    "validation"
  ],
  "patient": {
    "reference": "Patient/pat1"
  },
  "created": "2014-08-16",
  "request": {
    "reference": "http://www.BenefitsInc.com/fhir/coverageeligibilityrequest/225476332402"
  },
  "outcome": "complete",
  "disposition": "Policy is currently in-force.",
  "insurer": {
    "reference": "Organization/2"
  },
  "insurance": [
    {
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "inforce": true
    }
  ],
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}

Data Fields

Data Field	Type	Description
resourceType	CoverageEligibilityResponse	This is a CoverageEligibilityResponse 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.
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 this resource was created.
requestor	Reference	The provider which is responsible for the request.
request	Reference	Reference to the original request resource.
outcome	code	The outcome of the request processing.
disposition	string	A human readable description of the status of the adjudication.
insurer	Reference	The Insurer who issued the coverage in question and is the author of the response.
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.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.inforce	boolean	Flag indicating if the coverage provided is inforce currently if no service date(s) specified or for the whole duration of the service dates.
insurance.benefitPeriod	Period	The term of the benefits documented in this response.
insurance.item	BackboneElement	Benefits and optionally current balances, and authorization details by category or service.
insurance.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.
insurance.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.
insurance.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).
insurance.item.category	CodeableConcept	Code to identify the general type of benefits under which products and services are provided.
insurance.item.productOrService	CodeableConcept	This contains the product, service, drug or other billing code for the item.
insurance.item.modifier	CodeableConcept	Item typification or modifiers codes to convey additional context for the product or service.
insurance.item.provider	Reference	The practitioner who is eligible for the provision of the product or service.
insurance.item.excluded	boolean	True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
insurance.item.name	string	A short name or tag for the benefit.
insurance.item.description	string	A richer description of the benefit or services covered.
insurance.item.network	CodeableConcept	Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
insurance.item.unit	CodeableConcept	Indicates if the benefits apply to an individual or to the family.
insurance.item.term	CodeableConcept	The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
insurance.item.benefit	BackboneElement	Benefits used to date.
insurance.item.benefit.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.item.benefit.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.item.benefit.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.item.benefit.type	CodeableConcept	Classification of benefit being provided.
insurance.item.benefit.allowedUnsignedInt	number	The quantity of the benefit which is permitted under the coverage.
insurance.item.benefit.allowedString	string	The quantity of the benefit which is permitted under the coverage.
insurance.item.benefit.allowedMoney	Money	The quantity of the benefit which is permitted under the coverage.
insurance.item.benefit.usedUnsignedInt	number	The quantity of the benefit which have been consumed to date.
insurance.item.benefit.usedString	string	The quantity of the benefit which have been consumed to date.
insurance.item.benefit.usedMoney	Money	The quantity of the benefit which have been consumed to date.
insurance.item.authorizationRequired	boolean	A boolean flag indicating whether a preauthorization is required prior to actual service delivery.
insurance.item.authorizationSupporting	CodeableConcept	Codes or comments regarding information or actions associated with the preauthorization.
insurance.item.authorizationUrl	uri	A web location for obtaining requirements or descriptive information regarding the preauthorization.
preAuthRef	string	A reference from the Insurer to which these services pertain to be used on further communication and as proof that the request occurred.
form	CodeableConcept	A code for the form to be used for printing the content.
error	BackboneElement	Errors encountered during the processing of the request.
error.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
error.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.
error.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).
error.code	CodeableConcept	An error code,from a specified code system, which details why the eligibility check could not be performed.

Extensions

Name	URL
ANSI271	http://xcaliber-fhir/structureDefinition/ansi-271
SERVICETYPECODE	http://xcaliber-fhir/structureDefinition/service-type-code

CoverageEligibilityResponse

Overview

Use Cases

EHR Data Model

Object Definition

Data Fields

Extensions

Operations & APIs

CoverageEligibilityResponse-GET

CoverageEligibilityResponse-POST

CoverageEligibilityResponse ID-GET

CoverageEligibilityResponse ID-PUT

CoverageEligibilityResponse ID-DELETE