Coverage eligibility request

The provider asks the payer whether a policy is live, what it covers, and what a package will need. One CoverageEligibilityRequest carries all of that, and purpose decides which question is asked. It is the first exchange in a case, sent at registration or before treatment planning.

Sent on /v1/coverageeligibility/check, answered on /v1/coverageeligibility/on_check.

The bundle

#	Resource	Profile
1	`CoverageEligibilityRequest`	CoverageEligibilityRequest
2	`Patient`	Patient
3	`Organization (prov)`	Organization
4	`Organization (pay)`	Organization
5	`Location`	none declared; NRCeS Location
6	`Coverage`	Coverage
7	`PractitionerRole`	PractitionerRole

Elements

1. CoverageEligibilityRequest

NRCeS profile: CoverageEligibilityRequest.

Element	Example
`identifier[]`	system `https://nhcx.abdm.gov.in`
`status`	`active`
`priority.coding[]`	`normal` Normal in `http://terminology.hl7.org/CodeSystem/processpriority`
`purpose`	`auth-requirements`
`patient`	reference `https://nhcx.abdm.gov.in/patient`
`created`	`2026-09-10T23:53:57+05:30`
`enterer`	reference `https://nhcx.abdm.gov.in/practitioner-role`
`provider`	reference `https://nhcx.abdm.gov.in/provider`
`insurer`	reference `https://nhcx.abdm.gov.in/payer`
`facility`	reference `https://nhcx.abdm.gov.in/location`
`insurance[]`	focal `true`
`insurance[].coverage`	reference `https://nhcx.abdm.gov.in/coverage`
`item[].category.coding[]`	`Surgical` Surgical in `https://nhcx.abdm.gov.in/category-code`
`item[].productOrService.coding[]`	`PROC-KNEE-01` Total Knee Replacement (Unilateral) in `https://nhcx.abdm.gov.in/product-code`
`item[].quantity`	value `1`

2. Patient

NRCeS profile: Patient.

Element	Example
`identifier[]`	value `MRAV1985001`
`identifier[].type.coding[]`	`PMJAY` Pradhan Mantri Jan Aarogya Yojana (PMJAY) ID in `https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code`
	`MB` Member Number in `http://terminology.hl7.org/CodeSystem/v2-0203`

3. Organization (prov)

NRCeS profile: Organization.

Element	Example
`identifier[]`	system `https://nhcx.abdm.gov.in`, value `IN1910000151`
`identifier[].type.coding[]`	`NPI` National provider identifier in `http://terminology.hl7.org/CodeSystem/v2-0203`
`type[].coding[]`	`prov` Healthcare Provider in `http://terminology.hl7.org/CodeSystem/organization-type`
`name`	`KyroCare Multispeciality Hospital`

4. Organization (pay)

NRCeS profile: Organization.

Element	Example
`identifier[]`	system `https://nhcx.abdm.gov.in`, value `1000004805`
`identifier[].type.coding[]`	`NIIP` National Insurance Payor Identifier (Payor) in `http://terminology.hl7.org/CodeSystem/v2-0203`
`type[].coding[]`	`pay` Payer in `http://terminology.hl7.org/CodeSystem/organization-type`
`name`	`Sandbox Payer`

5. Location

NRCeS profile: Location.

Element	Example
`name`	`KyroCare Multispeciality Hospital`
`managingOrganization`	reference `https://nhcx.abdm.gov.in/provider`

6. Coverage

NRCeS profile: Coverage.

Element	Example
`status`	`active`
`type.coding[]`	`HIP` health insurance plan policy in `http://terminology.hl7.org/CodeSystem/v3-ActCode`
`identifier[]`	value `POL7UMU001`
`identifier[].type.coding[]`	`NH` National Health Plan Identifier in `http://terminology.hl7.org/CodeSystem/v2-0203`
`subscriber`	reference `https://nhcx.abdm.gov.in/patient`
`subscriberId`	`MRAV1985001`
`beneficiary`	reference `https://nhcx.abdm.gov.in/patient`
`relationship.coding[]`	`self` in `http://terminology.hl7.org/CodeSystem/subscriber-relationship`
`payor[]`	reference `https://nhcx.abdm.gov.in/payer`

7. PractitionerRole

NRCeS profile: PractitionerRole.

Element	Example
`code[].coding[]`	`307988006` Medical technician in `http://snomed.info/sct`

The four purposes

One builder, with purpose switched. The purposes differ in what they send and what the payer must return.

Variant	What it asks	purpose	item
Discovery	Which policies does this person hold? Searches by ABHA or demographic identifiers.	`discovery`	none
Validation	Is the policy in force, and what is left in the wallet?	`validation`	none
Benefits	Is this package covered for this beneficiary?	`benefits`	`MG004C` Dengue shock syndrome (Dengue fever) in `https://nhcx.abdm.gov.in/product-code`
Auth-requirements	What must a preauthorisation carry for this package?	`auth-requirements`	`MG004C` Dengue shock syndrome (Dengue fever) in `https://nhcx.abdm.gov.in/product-code`

Rules

1. One purpose per request

purpose[] carries one of discovery, validation, benefits, auth-requirements.

2. Items make a question answerable

item[] is what makes benefits and auth-requirements answerable. validation does not need it. discovery omits item[] and Coverage.

3. Date of service

servicedDate is the date of service, not the date of asking.

4. The Coverage you send is a stub

It names the policy you mean, not its terms. Take the term and the class from the payer's Coverage in the response.

5. Parties by reference

provider and insurer reference Organization entries typed prov and pay, identified by NPI and NIIP. facility references a Location the provider manages, and enterer a PractitionerRole.

PMJAY

The generic bundle above is what every payer takes, IRDAI-regulated insurers and TPAs included. PMJAY takes it with the changes and requirements below.

What changes in the bundle

Elements PMJAY adds

Element	Example
`CoverageEligibilityRequest.item[].modifier[].coding[]`	`STRAT006a` Routine Ward

What PMJAY specifies

item.category is the package master's specialty code, such as MG, and item.productOrService the master's package code and display.
The Coverage carries the scheme policy code typed NH, of the form PMJAY/<state>/S/G, from the policy lookup.
Validation after registration returns the wallet; benefits and auth-requirements before a preauthorisation return what the package needs attached, including the consent questionnaire when there is no biometric token.

What PMJAY requires

The ward tier rides as item.modifier when the package allows one.
Register the patient only after coverage is validated, and validate again every time treatment is added.

Use cases, APIs and data elements

B1 Check coverage eligibility (provider)

Is the policy in force, what is left in the wallet, and what must be attached. One endpoint, four purposes: discovery, validation, benefits, auth-requirements.


API	`/v1/coverageeligibility/check` `apis/02-eligibility/v1-coverageeligibility-check.bru`
Callback	`/v1/coverageeligibility/on_check` `apis/02-eligibility/v1-coverageeligibility-on-check.bru`
Workflow	none; sits beside registration 10 and admission 11
Carries JWE	yes
Focal resource	`CoverageEligibilityRequest`

Request headers

Header	Example value
`x-hcx-sender_code`	`1000004446@hcx`
`x-hcx-recipient_code`	`1518@hcx`
`x-hcx-api_call_id`	`{{$guid}}`
`x-hcx-request_id`	`{{$guid}}`
`x-hcx-correlation_id`	`{{$guid}}`
`x-hcx-workflow_id`	`11`
`x-hcx-timestamp`	`{{$isoTimestamp}}`
`x-hcx-status`	`request.initiated`
`x-hcx-ben-abha-id`	`91711234567890`

Workflow codes

Code	Name	Authored by	`x-hcx-status`	Means
`10`	Patient Registered	provider	`request.initiated`	Patient registered in system
`11`	Patient Admitted	provider	`request.initiated`	Patient admitted to hospital

Data elements

Element	Label	Group	Type	Card.	FHIR path	Example	Notes
`purpose`	Eligibility Purpose	Case	`code`	`1..1`	`CoverageEligibilityRequest.purpose[0]`	`auth-requirements`	code system `http://hl7.org/fhir/eligibilityrequest-purpose`
`caseNumber`	Provider Reference	Case	`string`	`1..1`	`CoverageEligibilityRequest.identifier[0].value`	`PA0000000001`	also at `Bundle.id`
`servicedDate`	Date of Service	Case	`date`	`1..1`	`CoverageEligibilityRequest.servicedDate`	`2026-02-26`
`patientName`	Patient Full Name	Beneficiary	`string`	`1..1`	`Patient.name[0].text`	`Ramesh Chandra Sharma`
`memberId`	Scheme / Insurer Member ID	Beneficiary	`string`	`1..1`	`Patient.identifier[type=PMJAY].value`	`PMJAY-HP-2024-998811`	also at `Coverage.subscriberId`
`abhaNumber`	ABHA Number	Beneficiary	`string`	`0..1`	`Patient.identifier[type=ABHA].value`	`91234567890123`
`gender`	Gender	Beneficiary	`code`	`1..1`	`Patient.gender`	`male`	code system `http://hl7.org/fhir/administrative-gender`
`birthDate`	Date of Birth	Beneficiary	`date`	`1..1`	`Patient.birthDate`	`1982-06-15`
`patientPhone`	Mobile Phone	Beneficiary	`string`	`0..1`	`Patient.telecom[system=phone].value`	`9876543210`
`policyNumber`	Policy Number	Coverage	`string`	`1..1`	`Coverage.identifier[0].value`	`PMJAY/HP/S/G`
`facilityId`	Hospital Facility ID (HFR/NPI)	Provider	`string`	`1..1`	`Organization[type=prov].identifier[system=https://facility.abdm.gov.in].value`	`IN1910000151`
`providerName`	Hospital Name	Provider	`string`	`1..1`	`Organization[type=prov].name`	`Apex Multispeciality Hospital`
`payerId`	Payer Identifier (NIIP)	Payer	`string`	`1..1`	`Organization[type=pay].identifier[system=https://irdai.gov.in].value`	`1000003538`
`payerName`	Payer Name	Payer	`string`	`1..1`	`Organization[type=pay].name`	`National Health Authority - PMJAY`
`productOrService`	Package Code	Item	`string`	`0..*`	`CoverageEligibilityRequest.item[].productOrService.coding[0].code`	`MG004A`

NRCeS profiles: CoverageEligibilityRequest, Patient, Coverage, Organization.

D3 Check coverage eligibility (pmjay)

Validation after registration returns the wallet, one benefit entry per wallet with allowed and used. Benefits and auth-requirements before a pre-authorisation return what the package needs attached. Register only after coverage is validated, and validate again every time treatment is added.


API	`/v1/coverageeligibility/check` `apis/02-eligibility/v1-coverageeligibility-check.bru`
Callback	`/v1/coverageeligibility/on_check` `apis/02-eligibility/v1-coverageeligibility-on-check.bru`
Workflow	none (or 5 under PMJAY)
Carries JWE	yes
Focal resource	`CoverageEligibilityRequest`

Request headers

Header	Example value
`x-hcx-sender_code`	`1000004446@hcx`
`x-hcx-recipient_code`	`1518@hcx`
`x-hcx-api_call_id`	`{{$guid}}`
`x-hcx-request_id`	`{{$guid}}`
`x-hcx-correlation_id`	`{{$guid}}`
`x-hcx-workflow_id`	`11`
`x-hcx-timestamp`	`{{$isoTimestamp}}`
`x-hcx-status`	`request.initiated`
`x-hcx-ben-abha-id`	`91711234567890`

Data elements

Element	Label	Group	Type	Card.	FHIR path	Example	Notes
`memberId`	PMJAY Family ID	Beneficiary	`string`	`1..1`	`Patient.identifier[type=PMJAY].value`	`PMJAY-HP-2024-998811`
`purpose`	Purpose	Case	`code`	`1..1`	`CoverageEligibilityRequest.purpose[0]`	`validation`

NRCeS profiles: CoverageEligibilityRequest, Patient.

The bundle​

Elements​

1. CoverageEligibilityRequest​

2. Patient​

3. Organization (prov)​

4. Organization (pay)​

5. Location​

6. Coverage​

7. PractitionerRole​

The four purposes​

Rules​

1. One purpose per request​

2. Items make a question answerable​

3. Date of service​

4. The Coverage you send is a stub​

5. Parties by reference​

PMJAY​

What changes in the bundle​

Elements PMJAY adds​

What PMJAY specifies​

What PMJAY requires​

Use cases, APIs and data elements​

B1 Check coverage eligibility (provider)​

D3 Check coverage eligibility (pmjay)​