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Eligibility FHIR Resource Proposal

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Eligibility

Owning committee name

Financial Management

Contributing or Reviewing Work Groups

FHIR Resource Development Project Insight ID

994

Scope of coverage

Represents more or less granular information requesting verification that a patient is enrolled in a public health program or private health insurance policy for which premiums are to be or have been paid, and for which types or specific healthcare services are covered. It includes requests for verification of coverage for humans as well as animals.

RIM scope

Observation class with classCode of VERIF and moodCode of RQO.

Resource appropriateness

Eligibility is used to query a public health program or private health insurer to verify that a patient's insurance policy (coverage) is in effect for a specified date and to determine the status of a patient's eligibility for healthcare services. The Eligibility response may impact what services will be rendered to the patient and who will pay for them.

Expected implementations

Referenced by CCDA in situations where coverage has is not yet effective, is effective, or has lapsed.

Content sources

  • v2 IN1, IN2, IN3 segments
  • v3 Eligibility and Coverage models
  • X12 270, 271, 834, 820
  • NCPDP

Example Scenarios

Provider verification of patient’s coverage prior to rendering healthcare services.

Resource Relationships

Eligibility is associated to Coverage, Patients as covered parties, and RelatedPersons or Organizations as policy holders.

Eligibility is referenced by Eligibility Response.

Timelines

Part of initial DSTU.

gForge Users

N/A