Implementation Guide
23.1.0 - R4 APIs

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Logical Model: Profile - Athena Custom Eligibility

Official URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-eligibility-profile Version: 23.1.0
Active as of 2023-03-01 Computable Name: Eligibility

The Eligibility is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services.


This Eligibility profile is part of the custom resource profiles supported by the API server used with the Athena Practice product used with the athenaPractice 23.0.0. This is not a FHIR Conformant Resource. It further describes read and search capabilities of these products.
Note: Create and Update operations are NOT supported for this resource.

Overview

The Eligibility resource provides medical insurance coverage information for patients. This information includes stated coverage is valid and in-force and optionally to provide the insurance details of the policy and potentially the amount of coverage which may be available to any services classes identified.

Scope and Usage

This profile is used to define the content that will be returned by the API Server in response to requests to access Eligibility resources. All elements listed in the differential profile view are Supported, which means that the API Server is capable of supplying these fields from the product database when they have been populated via the product or its APIs.

Source

The Eligibility resource contains patient eligibility information from a given insurer. This information is extracted from PatientInsurance, InsuranceCarriers, MedLists, PatientProfile tables.

Example

Example for the athena-eligibility-profile Profile.

Eligibility Example

Usage:

  • This Logical Model Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-eligibility-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid SΣ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
... patient 0..1 Reference(Patient) Who/what is the patient for Eligibility
.... reference 0..1 string Reference to the Patient
.... display 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... orderForClaims 0..1 integer Claims-order link to the patient visit
... patientInsuranceStatus 0..1 string Status of Patient insurance
... patientInsuranceGroupId 0..1 string Policy group number
... patientInsuranceGroupName 0..1 string Policy group name
... claimOfficeNumber 0..1 string Office number of Claim.
... insuredId 0..1 string Insured person's insurance ID
... patientInsuranceMediGapId 0..1 string The Medigap ID for this insurance carrier if the policy type is set to Medigap.
... insuranceCardEffectiveDate 0..1 dateTime Effective date of this insurance policy.
... insuranceCardTerminationDate 0..1 dateTime Termination date of this insurance policy.
... patientCopayAmount 0..1 Money Patient copay for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... patientInsuranceDeductible 0..1 Money Patient Insurance deductible 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... champusBranch 0..1 string A CHAMPUS branch identifies and tracks the branch of the military to which a patient belongs.
... champusGrade 0..1 string A CHAMPUS Grade list option identifies and tracks the ranking of a patient in the military
... champusStatus 0..1 string A CHAMPUS status identifies and tracks the status of a patient in the military (whether active or retired).
... patientRelatedToInsured 0..1 string Relation of patient with the Insured person.
... employer 0..1 Reference(Organization) Employer details
.... reference 0..1 string Insurance Carrier Id refering to employer
.... display 0..1 string Insurance carrier Name
... employeeId 0..1 string Identifier for Employee
... eligibilityVerified 0..1 integer Integer code for the eligibility status for this insurance carrier for this patient
... eligibilityVerifiedDate 0..1 dateTime Date the eligibility information was verified.
... eligibilityVerifiedBy 0..1 string Person who has verified Eligibility.
... eligibilityNotes 0..1 string Notes from this insurance carrier about the eligibility for this patient.
... patientInsuranceNotes 0..1 string InsuranceNotes related to patient
... insurancePolicyTypes 0..1 string Insurance policy type
... dateOfServiceFrom 0..1 dateTime Start date of service for this procedure
... dateOfServiceTo 0..1 dateTime Stop date of service for this procedure.
... otherInsuredId 0..1 string Insured person's another insurance ID
... otherIdQualifier 0..1 string OtherId Qualifier
... otherCopayAmount 0..1 Money OtherCopayAmt for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... familyDeductible 0..1 Money FamilyDeductible for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... coInsurance 0..1 Money CoInsurance for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... otherDeductible 0..1 Money OtherDeductible for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... masterInsuranceCarriersId 0..1 integer If this carrier was imported from the master list, then this is the ID of the carrier that was imported.
... inactiveInsuranceCarrier 0..1 boolean Flag for insurance carrier is marked inactive.
... insuranceCarrier 0..1 Reference(Organization) insurance Carrier details
.... reference 0..1 string Insurance Carrier Id refering to Organization
.... display 0..1 string Insurance carrier Name
... collectionsGroup 0..1 string Collections group to which this insurance carrier belongs.
... carrierType 0..1 string Carrier type of this insurance carrier.
... carrierTypeANSI 0..1 string Carrier type ANSI of this insurance carrier
... patientFinancialClass 0..1 string Financial class of this insurance carrier.
... insuranceGroupName 0..1 string Insurance Group Name.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-eligibility-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid SΣ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
... patient C 0..1 Reference(Patient) Who/what is the patient for Eligibility
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Reference to the Patient
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... orderForClaims 0..1 integer Claims-order link to the patient visit
... patientInsuranceStatus 0..1 string Status of Patient insurance
... patientInsuranceGroupId 0..1 string Policy group number
... patientInsuranceGroupName 0..1 string Policy group name
... claimOfficeNumber 0..1 string Office number of Claim.
... insuredId 0..1 string Insured person's insurance ID
... patientInsuranceMediGapId 0..1 string The Medigap ID for this insurance carrier if the policy type is set to Medigap.
... insuranceCardEffectiveDate 0..1 dateTime Effective date of this insurance policy.
... insuranceCardTerminationDate 0..1 dateTime Termination date of this insurance policy.
... patientCopayAmount 0..1 Money Patient copay for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... patientInsuranceDeductible 0..1 Money Patient Insurance deductible 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... champusBranch 0..1 string A CHAMPUS branch identifies and tracks the branch of the military to which a patient belongs.
... champusGrade 0..1 string A CHAMPUS Grade list option identifies and tracks the ranking of a patient in the military
... champusStatus 0..1 string A CHAMPUS status identifies and tracks the status of a patient in the military (whether active or retired).
... patientRelatedToInsured 0..1 string Relation of patient with the Insured person.
... employer C 0..1 Reference(Organization) Employer details
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Insurance Carrier Id refering to employer
.... display Σ 0..1 string Insurance carrier Name
... employeeId 0..1 string Identifier for Employee
... eligibilityVerified 0..1 integer Integer code for the eligibility status for this insurance carrier for this patient
... eligibilityVerifiedDate 0..1 dateTime Date the eligibility information was verified.
... eligibilityVerifiedBy 0..1 string Person who has verified Eligibility.
... eligibilityNotes 0..1 string Notes from this insurance carrier about the eligibility for this patient.
... patientInsuranceNotes 0..1 string InsuranceNotes related to patient
... insurancePolicyTypes 0..1 string Insurance policy type
... dateOfServiceFrom 0..1 dateTime Start date of service for this procedure
... dateOfServiceTo 0..1 dateTime Stop date of service for this procedure.
... otherInsuredId 0..1 string Insured person's another insurance ID
... otherIdQualifier 0..1 string OtherId Qualifier
... otherCopayAmount 0..1 Money OtherCopayAmt for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... familyDeductible 0..1 Money FamilyDeductible for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... coInsurance 0..1 Money CoInsurance for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... otherDeductible 0..1 Money OtherDeductible for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... masterInsuranceCarriersId 0..1 integer If this carrier was imported from the master list, then this is the ID of the carrier that was imported.
... inactiveInsuranceCarrier 0..1 boolean Flag for insurance carrier is marked inactive.
... insuranceCarrier C 0..1 Reference(Organization) insurance Carrier details
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... display Σ 0..1 string Insurance carrier Name
... collectionsGroup 0..1 string Collections group to which this insurance carrier belongs.
... carrierType 0..1 string Carrier type of this insurance carrier.
... carrierTypeANSI 0..1 string Carrier type ANSI of this insurance carrier
... patientFinancialClass 0..1 string Financial class of this insurance carrier.
... insuranceGroupName 0..1 string Insurance Group Name.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-eligibility-profile.patientCopayAmount.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.patientInsuranceDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.otherCopayAmount.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.familyDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.coInsurance.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.otherDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-eligibility-profile.patient, athena-eligibility-profile.employer, athena-eligibility-profile.insuranceCarrierSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-eligibility-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid SΣ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
... patient C 0..1 Reference(Patient) Who/what is the patient for Eligibility
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Reference to the Patient
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... orderForClaims 0..1 integer Claims-order link to the patient visit
... patientInsuranceStatus 0..1 string Status of Patient insurance
... patientInsuranceGroupId 0..1 string Policy group number
... patientInsuranceGroupName 0..1 string Policy group name
... claimOfficeNumber 0..1 string Office number of Claim.
... insuredId 0..1 string Insured person's insurance ID
... patientInsuranceMediGapId 0..1 string The Medigap ID for this insurance carrier if the policy type is set to Medigap.
... insuranceCardEffectiveDate 0..1 dateTime Effective date of this insurance policy.
... insuranceCardTerminationDate 0..1 dateTime Termination date of this insurance policy.
... patientCopayAmount 0..1 Money Patient copay for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... patientInsuranceDeductible 0..1 Money Patient Insurance deductible 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... champusBranch 0..1 string A CHAMPUS branch identifies and tracks the branch of the military to which a patient belongs.
... champusGrade 0..1 string A CHAMPUS Grade list option identifies and tracks the ranking of a patient in the military
... champusStatus 0..1 string A CHAMPUS status identifies and tracks the status of a patient in the military (whether active or retired).
... patientRelatedToInsured 0..1 string Relation of patient with the Insured person.
... employer C 0..1 Reference(Organization) Employer details
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Insurance Carrier Id refering to employer
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Insurance carrier Name
... employeeId 0..1 string Identifier for Employee
... eligibilityVerified 0..1 integer Integer code for the eligibility status for this insurance carrier for this patient
... eligibilityVerifiedDate 0..1 dateTime Date the eligibility information was verified.
... eligibilityVerifiedBy 0..1 string Person who has verified Eligibility.
... eligibilityNotes 0..1 string Notes from this insurance carrier about the eligibility for this patient.
... patientInsuranceNotes 0..1 string InsuranceNotes related to patient
... insurancePolicyTypes 0..1 string Insurance policy type
... dateOfServiceFrom 0..1 dateTime Start date of service for this procedure
... dateOfServiceTo 0..1 dateTime Stop date of service for this procedure.
... otherInsuredId 0..1 string Insured person's another insurance ID
... otherIdQualifier 0..1 string OtherId Qualifier
... otherCopayAmount 0..1 Money OtherCopayAmt for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... familyDeductible 0..1 Money FamilyDeductible for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... coInsurance 0..1 Money CoInsurance for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... otherDeductible 0..1 Money OtherDeductible for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... masterInsuranceCarriersId 0..1 integer If this carrier was imported from the master list, then this is the ID of the carrier that was imported.
... inactiveInsuranceCarrier 0..1 boolean Flag for insurance carrier is marked inactive.
... insuranceCarrier C 0..1 Reference(Organization) insurance Carrier details
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Insurance carrier Name
... collectionsGroup 0..1 string Collections group to which this insurance carrier belongs.
... carrierType 0..1 string Carrier type of this insurance carrier.
... carrierTypeANSI 0..1 string Carrier type ANSI of this insurance carrier
... patientFinancialClass 0..1 string Financial class of this insurance carrier.
... insuranceGroupName 0..1 string Insurance Group Name.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-eligibility-profile.patient.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-eligibility-profile.patientCopayAmount.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.patientInsuranceDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.employer.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-eligibility-profile.otherCopayAmount.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.familyDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.coInsurance.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.otherDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.insuranceCarrier.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-eligibility-profile.patient, athena-eligibility-profile.employer, athena-eligibility-profile.insuranceCarrierSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from Base

Summary

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

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-eligibility-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid SΣ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
... patient 0..1 Reference(Patient) Who/what is the patient for Eligibility
.... reference 0..1 string Reference to the Patient
.... display 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... orderForClaims 0..1 integer Claims-order link to the patient visit
... patientInsuranceStatus 0..1 string Status of Patient insurance
... patientInsuranceGroupId 0..1 string Policy group number
... patientInsuranceGroupName 0..1 string Policy group name
... claimOfficeNumber 0..1 string Office number of Claim.
... insuredId 0..1 string Insured person's insurance ID
... patientInsuranceMediGapId 0..1 string The Medigap ID for this insurance carrier if the policy type is set to Medigap.
... insuranceCardEffectiveDate 0..1 dateTime Effective date of this insurance policy.
... insuranceCardTerminationDate 0..1 dateTime Termination date of this insurance policy.
... patientCopayAmount 0..1 Money Patient copay for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... patientInsuranceDeductible 0..1 Money Patient Insurance deductible 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... champusBranch 0..1 string A CHAMPUS branch identifies and tracks the branch of the military to which a patient belongs.
... champusGrade 0..1 string A CHAMPUS Grade list option identifies and tracks the ranking of a patient in the military
... champusStatus 0..1 string A CHAMPUS status identifies and tracks the status of a patient in the military (whether active or retired).
... patientRelatedToInsured 0..1 string Relation of patient with the Insured person.
... employer 0..1 Reference(Organization) Employer details
.... reference 0..1 string Insurance Carrier Id refering to employer
.... display 0..1 string Insurance carrier Name
... employeeId 0..1 string Identifier for Employee
... eligibilityVerified 0..1 integer Integer code for the eligibility status for this insurance carrier for this patient
... eligibilityVerifiedDate 0..1 dateTime Date the eligibility information was verified.
... eligibilityVerifiedBy 0..1 string Person who has verified Eligibility.
... eligibilityNotes 0..1 string Notes from this insurance carrier about the eligibility for this patient.
... patientInsuranceNotes 0..1 string InsuranceNotes related to patient
... insurancePolicyTypes 0..1 string Insurance policy type
... dateOfServiceFrom 0..1 dateTime Start date of service for this procedure
... dateOfServiceTo 0..1 dateTime Stop date of service for this procedure.
... otherInsuredId 0..1 string Insured person's another insurance ID
... otherIdQualifier 0..1 string OtherId Qualifier
... otherCopayAmount 0..1 Money OtherCopayAmt for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... familyDeductible 0..1 Money FamilyDeductible for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... coInsurance 0..1 Money CoInsurance for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... otherDeductible 0..1 Money OtherDeductible for each Insurance Eligibility 271 parsed response
.... value 0..1 decimal Money value
.... currency 0..1 code Currency
... masterInsuranceCarriersId 0..1 integer If this carrier was imported from the master list, then this is the ID of the carrier that was imported.
... inactiveInsuranceCarrier 0..1 boolean Flag for insurance carrier is marked inactive.
... insuranceCarrier 0..1 Reference(Organization) insurance Carrier details
.... reference 0..1 string Insurance Carrier Id refering to Organization
.... display 0..1 string Insurance carrier Name
... collectionsGroup 0..1 string Collections group to which this insurance carrier belongs.
... carrierType 0..1 string Carrier type of this insurance carrier.
... carrierTypeANSI 0..1 string Carrier type ANSI of this insurance carrier
... patientFinancialClass 0..1 string Financial class of this insurance carrier.
... insuranceGroupName 0..1 string Insurance Group Name.

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-eligibility-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid SΣ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
... patient C 0..1 Reference(Patient) Who/what is the patient for Eligibility
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Reference to the Patient
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... orderForClaims 0..1 integer Claims-order link to the patient visit
... patientInsuranceStatus 0..1 string Status of Patient insurance
... patientInsuranceGroupId 0..1 string Policy group number
... patientInsuranceGroupName 0..1 string Policy group name
... claimOfficeNumber 0..1 string Office number of Claim.
... insuredId 0..1 string Insured person's insurance ID
... patientInsuranceMediGapId 0..1 string The Medigap ID for this insurance carrier if the policy type is set to Medigap.
... insuranceCardEffectiveDate 0..1 dateTime Effective date of this insurance policy.
... insuranceCardTerminationDate 0..1 dateTime Termination date of this insurance policy.
... patientCopayAmount 0..1 Money Patient copay for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... patientInsuranceDeductible 0..1 Money Patient Insurance deductible 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... champusBranch 0..1 string A CHAMPUS branch identifies and tracks the branch of the military to which a patient belongs.
... champusGrade 0..1 string A CHAMPUS Grade list option identifies and tracks the ranking of a patient in the military
... champusStatus 0..1 string A CHAMPUS status identifies and tracks the status of a patient in the military (whether active or retired).
... patientRelatedToInsured 0..1 string Relation of patient with the Insured person.
... employer C 0..1 Reference(Organization) Employer details
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Insurance Carrier Id refering to employer
.... display Σ 0..1 string Insurance carrier Name
... employeeId 0..1 string Identifier for Employee
... eligibilityVerified 0..1 integer Integer code for the eligibility status for this insurance carrier for this patient
... eligibilityVerifiedDate 0..1 dateTime Date the eligibility information was verified.
... eligibilityVerifiedBy 0..1 string Person who has verified Eligibility.
... eligibilityNotes 0..1 string Notes from this insurance carrier about the eligibility for this patient.
... patientInsuranceNotes 0..1 string InsuranceNotes related to patient
... insurancePolicyTypes 0..1 string Insurance policy type
... dateOfServiceFrom 0..1 dateTime Start date of service for this procedure
... dateOfServiceTo 0..1 dateTime Stop date of service for this procedure.
... otherInsuredId 0..1 string Insured person's another insurance ID
... otherIdQualifier 0..1 string OtherId Qualifier
... otherCopayAmount 0..1 Money OtherCopayAmt for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... familyDeductible 0..1 Money FamilyDeductible for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... coInsurance 0..1 Money CoInsurance for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... otherDeductible 0..1 Money OtherDeductible for each Insurance Eligibility 271 parsed response
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... masterInsuranceCarriersId 0..1 integer If this carrier was imported from the master list, then this is the ID of the carrier that was imported.
... inactiveInsuranceCarrier 0..1 boolean Flag for insurance carrier is marked inactive.
... insuranceCarrier C 0..1 Reference(Organization) insurance Carrier details
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... display Σ 0..1 string Insurance carrier Name
... collectionsGroup 0..1 string Collections group to which this insurance carrier belongs.
... carrierType 0..1 string Carrier type of this insurance carrier.
... carrierTypeANSI 0..1 string Carrier type ANSI of this insurance carrier
... patientFinancialClass 0..1 string Financial class of this insurance carrier.
... insuranceGroupName 0..1 string Insurance Group Name.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-eligibility-profile.patientCopayAmount.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.patientInsuranceDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.otherCopayAmount.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.familyDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.coInsurance.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.otherDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-eligibility-profile.patient, athena-eligibility-profile.employer, athena-eligibility-profile.insuranceCarrierSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-eligibility-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid SΣ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
... patient C 0..1 Reference(Patient) Who/what is the patient for Eligibility
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Reference to the Patient
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... orderForClaims 0..1 integer Claims-order link to the patient visit
... patientInsuranceStatus 0..1 string Status of Patient insurance
... patientInsuranceGroupId 0..1 string Policy group number
... patientInsuranceGroupName 0..1 string Policy group name
... claimOfficeNumber 0..1 string Office number of Claim.
... insuredId 0..1 string Insured person's insurance ID
... patientInsuranceMediGapId 0..1 string The Medigap ID for this insurance carrier if the policy type is set to Medigap.
... insuranceCardEffectiveDate 0..1 dateTime Effective date of this insurance policy.
... insuranceCardTerminationDate 0..1 dateTime Termination date of this insurance policy.
... patientCopayAmount 0..1 Money Patient copay for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... patientInsuranceDeductible 0..1 Money Patient Insurance deductible 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... champusBranch 0..1 string A CHAMPUS branch identifies and tracks the branch of the military to which a patient belongs.
... champusGrade 0..1 string A CHAMPUS Grade list option identifies and tracks the ranking of a patient in the military
... champusStatus 0..1 string A CHAMPUS status identifies and tracks the status of a patient in the military (whether active or retired).
... patientRelatedToInsured 0..1 string Relation of patient with the Insured person.
... employer C 0..1 Reference(Organization) Employer details
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Insurance Carrier Id refering to employer
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Insurance carrier Name
... employeeId 0..1 string Identifier for Employee
... eligibilityVerified 0..1 integer Integer code for the eligibility status for this insurance carrier for this patient
... eligibilityVerifiedDate 0..1 dateTime Date the eligibility information was verified.
... eligibilityVerifiedBy 0..1 string Person who has verified Eligibility.
... eligibilityNotes 0..1 string Notes from this insurance carrier about the eligibility for this patient.
... patientInsuranceNotes 0..1 string InsuranceNotes related to patient
... insurancePolicyTypes 0..1 string Insurance policy type
... dateOfServiceFrom 0..1 dateTime Start date of service for this procedure
... dateOfServiceTo 0..1 dateTime Stop date of service for this procedure.
... otherInsuredId 0..1 string Insured person's another insurance ID
... otherIdQualifier 0..1 string OtherId Qualifier
... otherCopayAmount 0..1 Money OtherCopayAmt for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... familyDeductible 0..1 Money FamilyDeductible for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... coInsurance 0..1 Money CoInsurance for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... otherDeductible 0..1 Money OtherDeductible for each Insurance Eligibility 271 parsed response
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Money value
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... masterInsuranceCarriersId 0..1 integer If this carrier was imported from the master list, then this is the ID of the carrier that was imported.
... inactiveInsuranceCarrier 0..1 boolean Flag for insurance carrier is marked inactive.
... insuranceCarrier C 0..1 Reference(Organization) insurance Carrier details
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Insurance carrier Name
... collectionsGroup 0..1 string Collections group to which this insurance carrier belongs.
... carrierType 0..1 string Carrier type of this insurance carrier.
... carrierTypeANSI 0..1 string Carrier type ANSI of this insurance carrier
... patientFinancialClass 0..1 string Financial class of this insurance carrier.
... insuranceGroupName 0..1 string Insurance Group Name.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-eligibility-profile.patient.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-eligibility-profile.patientCopayAmount.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.patientInsuranceDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.employer.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-eligibility-profile.otherCopayAmount.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.familyDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.coInsurance.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.otherDeductible.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-eligibility-profile.insuranceCarrier.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-eligibility-profile.patient, athena-eligibility-profile.employer, athena-eligibility-profile.insuranceCarrierSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from Base

Summary

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

 

Other representations of profile: CSV, Excel

Notes:

Supported Interactions

The Interactions supported by this resource are listed below.

Search Parameters

Search parameters are executed as specified in the HL7 FHIR RESTful API implementation definition. To search for Eligibility resources, an application shall perform an HTTP GET, specifying the query parameters associated with the resource.

GET [base]/customresource/Eligibility?{search-parameters}

Where:

Name Description
[base] Specifies the base URL of the FHIR Server, e.g., https://ap22sandbox.athenahealth.com/demoAPIServer
_id (token) The ID of the resource
patientProfileId known id of the patient.
patient (reference) The patient this person is related to.
[_include] Specifies the supported hl7 resources include which are defined as reference in examples. Note: The Patient and Organization resources are supported via the _include parameter.
HTTP Response Codes

The following HTTP response codes are returned by this API call:

200 OK The query was performed and any results found are contained within the body of the HTTP response. Note: The search API will return 200 OK when the query itself is successful, regardless of whether or not any matching results were found.
401 Unauthorized Authorization is required for this request, and either the Authorization header is missing or the supplied user credentials in the Authorization header are not valid or have expired. The body of the HTTP response will contain an OperationOutcome resource that indicates that Authorization is required.
500 Server Error The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.