Coverage eligibility response

The payer's answer on on_check. It says whether the coverage is in force, what is left in the wallet, and which items need authorisation and which documents.

Sent on /v1/coverageeligibility/on_check.

The bundle​

Elements​

1. CoverageEligibilityResponse​

NRCeS profile: CoverageEligibilityResponse.

2. Patient​

NRCeS profile: Patient.

3. Coverage​

NRCeS profile: Coverage.

4. CoverageEligibilityRequest​

NRCeS profile: CoverageEligibilityRequest.

5. Organization (ins)​

NRCeS profile: Organization.

Rules​

1. Read the answer in three places​

outcome, insurance[].inforce and insurance[].item[]. disposition is prose for a human.

2. Match to the request by reference​

Use CoverageEligibilityResponse.request.reference, never a resource id, to join the answer to what you sent.

3. Index entries by fullUrl​

A response can carry more than one Patient or Organization. Index by fullUrl, not by resource type.

4. Money​

allowedMoney is the balance remaining and usedMoney the amount used, not the sum insured. There is one benefit per wallet; read them all.

5. Build for the fuller form​

benefit[] with Procedure, Investigation and Stratification types for benefits, and authorizationSupporting[] with the mandatory document codes for auth-requirements. Tolerate a leaner answer.

6. Documents by stage​

authorizationSupporting[] lists the documents the next request must carry. Its text names the stage: pre for the preauthorisation, post for the claim.

7. The identifier is not a correlation key​

CoverageEligibilityResponse.identifier identifies the beneficiary at the hospital. Correlate on the protocol headers.

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​

PMJAY uses a different bundle for this step, headed by CoverageEligibilityRequest rather than CoverageEligibilityResponse.

8. CoverageEligibilityResponse​

NRCeS profile: CoverageEligibilityResponse.

The CoverageEligibilityRequest, Patient, Organization, Location, Coverage, PractitionerRole entries are shaped as in the chapters that introduce them.

What PMJAY specifies​

• The bundle echoes the whole request first and then gives the answer, with the payer's own Patient, Coverage and both Organization entries.
• A PMJAY answer can carry only item.excluded and item.authorizationRequired, without benefitPeriod, benefit[] or authorizationSupporting[]. The documents then come from the plan.
• The payer's Patient can differ from yours in name, gender and birth date. Do not overwrite your record from it.

Use cases, APIs and data elements​

C3 Respond to coverage eligibility (payer)​

The eligibility and plan details for the beneficiary asked about. A payer may instead answer with a forward instruction, asking the exchange to pass the request to another payer.

Request headers

Data elements

NRCeS profiles: CoverageEligibilityResponse.