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CoverageEligibilityRequest

Overview​

The CoverageEligibilityRequest resource represents requests for insurance coverage eligibility verification. This resource enables healthcare providers to verify patient insurance coverage and benefits before providing services.

Important: Always validate CoverageEligibilityRequest resource support and available operations by retrieving the current CapabilityStatement from /metadata before implementing integrations.

Resource Schema​

The CoverageEligibilityRequest resource follows the HL7 FHIR R4 CoverageEligibilityRequest specification.

Key elements include:

  • identifier - Business identifiers for the request
  • status - Active, cancelled, draft, entered-in-error
  • priority - Desired processing urgency
  • purpose - Code to identify the general type of benefits
  • patient - Intended recipient of products and services
  • servicedDate - Estimated date or dates of service
  • servicedPeriod - Estimated date or dates of service
  • created - Resource creation date
  • enterer - Author of the request
  • provider - Party responsible for the request
  • insurer - Coverage issuer
  • facility - Servicing facility
  • supportingInfo - Supporting information
  • insurance - Patient insurance information
  • item - Item to be evaluated for eligibility

Example CoverageEligibilityRequest Resource​

{
  "resourceType": "CoverageEligibilityRequest",
  "id": "12345",
  "identifier": [{
    "system": "http://hospital.example.org/eligibility-requests",
    "value": "ER-2024-001"
  }],
  "status": "active",
  "priority": {
    "coding": [{
      "system": "http://terminology.hl7.org/CodeSystem/processpriority",
      "code": "normal"
    }]
  },
  "purpose": ["benefits"],
  "patient": {
    "reference": "Patient/12345"
  },
  "servicedDate": "2024-01-20",
  "created": "2024-01-15T10:30:00Z",
  "enterer": {
    "reference": "Practitioner/67890"
  },
  "provider": {
    "reference": "Organization/hospital-123"
  },
  "insurer": {
    "reference": "Organization/insurance-456"
  },
  "facility": {
    "reference": "Location/clinic-789"
  },
  "insurance": [{
    "focal": true,
    "coverage": {
      "reference": "Coverage/coverage-123"
    }
  }]
}

Supported Profiles​

This API supports the following FHIR profiles:

Operations​

info

Support for the different types of Conditions may vary by CareRecord. Please consult your target solution's documentation for more information.

The General Purpose FHIR R4 CoverageEligibilityRequest resource supports the following standard operations. However, support varies by the targeted CareRecord or solution.

CareRecord / SolutionCreateReadUpdateSearch
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This resource supports a combination of standard and custom search parameters in addition to the common parameters.

Standard Parameters​

NameTypeDescription
patientreferenceREQUIRED Unique identifier of the patient.

Custom Parameters​

NameTypeDescription
encounterreferenceUnique identifier of the Practitioner.

Search Examples​

The POST method is recommended as it keeps health information out of the URL.

Search by Patient
curl -X POST https://fhir.netsmartcloud.com/v4/CoverageEligibilityRequest/_search \
    -H "Authorization: {Bearer Token}" \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-form-urlencoded" \
    -d "patient=Patient/234"

Error Handling​

For information about error responses when working with CoverageEligibilityRequest resources, see Common Errors.

Common CoverageEligibilityRequest-related errors include:

  • Missing required patient reference
  • Invalid insurer or provider references
  • Malformed service dates
  • Invalid coverage references

Integration Patterns​

Pre-Service Verification​

Verify coverage before providing services:

# Create eligibility request
curl -X POST "https://fhir.netsmartcloud.com/v4/CoverageEligibilityRequest" \
    -H "Authorization: Bearer {token}" \
    -H "Content-Type: application/fhir+json" \
    -d @eligibility-request.json

Benefits Verification​

Check patient eligibility by patient:

# Get eligibility requests for patient
curl -X GET "https://fhir.netsmartcloud.com/v4/CoverageEligibilityRequest?patient=12345" \
    -H "Authorization: Bearer {token}" \
    -H "Accept: application/fhir+json"

Encounter-Based Verification​

Link eligibility checks to encounters:

# Get eligibility requests by encounter
curl -X GET "https://fhir.netsmartcloud.com/v4/CoverageEligibilityRequest?encounter=67890" \
    -H "Authorization: Bearer {token}" \
    -H "Accept: application/fhir+json"

Relationships to Other Resources​

The CoverageEligibilityRequest resource connects to several administrative resources:

Support​

For questions about CoverageEligibilityRequest resource implementation or insurance verification workflows, contact Netsmart support through your designated support channels.