CoverageEligibilityResponse
The CoverageEligibilityResponse resource provides eligibility and plan details from processing a CoverageEligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy benefit details as well as the ability for the insurer to indicate whether the insurance provides benefits for requested types of services or requires preauthorization and if so what supporting information may be required.
https://hl7.org/fhir/R4/coverageeligibilityresponse.html
CoverageEligibilityResponse read
Path Parameters
Response Payload Attributes
The FHIR Resource name.
The identifier of the CoverageEligibilityResponse.
Status of the resource.
Reason for the request, will always be [“benefits”]
Patient resource the CoverageEligibilityResponse is for.
The reference string of the patient in the format of "Patient/a39cafb9d1b445be95a2e2548e12a787".
Type the reference refers to (e.g. “Patient”).
Response creation date.
CoverageEligibilityRequest reference the elibibility response is for.
The reference string of the request in the format of "CoverageEligibilityRequest/cd98975b-6cd4-413d-ab65-1fc5eec76762".
Type the reference refers to (e.g. “CoverageEligibilityRequest”).
Outcome of the request processing, if an error occurs it will be marked as “error” othervise it will be marked as “complete”.
Coverage issuer.
Payor ID for the Coverage issuer.
Text alternative for the resource.
Patient insurance information. This includes the Coverage reference, extension for plan name and an array of items containing benefits and authorization details returned from Claim.MD.
The amount of information surfaced here depends on the what the payor supports. Our clearinghouse (Claim.md) performs these eligibility checks, but not all coverages will support real-time eligibility checks. For more information on coverages within Canvas, see this Zendesk article.
Insurance information.
The reference string of the coverage in the format of "Coverage/4a86f580-e192-489a-a9f0-7c915fc67111".
Type the reference refers to (e.g. “Coverage”).
Canvas supports a plan name extension on this resource for read and search interactions.
Reference that defines the content of this object.
The plan name of the insurance.
Array of items containing benefits and authorization details.
Short name for the benefit
Individual or family.
Code defined by a terminology system.
The system url of the coding.
The code of the benefit unit.
The display name of the coding.
Plain text representation of the concept.
In or out of network.
Code defined by a terminology system.
The system url of the coding.
The code of the benefit network.
The display name of the coding.
Plain text representation of the concept.
Benefit Summary.
Benefit classification.
Plain text representation of the concept.
Benefits allowed.
Used for Co-Insurance benefit types.
Benefits allowed.
Used for Co-Payment, Deductible, or Out of Pocket benefit types.
Numerical value (with implicit precision)
Benefits allowed.
Used for Limitations benefit types.
Benefits used.
Used for Deductible or Out of Pocket benefit types.
Numerical value (with implicit precision)
Benefits used.
Used for Limitations benefit types.
Responses
Errors
CoverageEligibilityResponse search
Query Parameters
The Canvas resource identifier of the CoverageEligibilityResponse.
The patient reference associated with the CoverageEligibilityResponse in the format Patient/a39cafb9d1b445be95a2e2548e12a787.
The coverage eligibility request reference associated with the CoverageEligibilityResponse in the format "CoverageEligibilityRequest/cd98975b-6cd4-413d-ab65-1fc5eec76762".
Response Payload Attributes
The FHIR Resource name.
This element and value designate that the bundle is a search response. Search result bundles will always have the Bundle.type of searchset .
The number of resources that match the search parameter.
Attributes relevant to pagination, see our Pagination page for more detail.
The relation of the page search
The search url for the specific relation
The results bundle that lists out each object returned in the search
The attributes specific to the resource type, see the Attributes section below
Attributes
The FHIR Resource name.
The identifier of the CoverageEligibilityResponse.
Status of the resource.
Reason for the request, will always be [“benefits”]
Patient resource the CoverageEligibilityResponse is for.
The reference string of the patient in the format of "Patient/a39cafb9d1b445be95a2e2548e12a787".
Type the reference refers to (e.g. “Patient”).
Response creation date.
CoverageEligibilityRequest reference the elibibility response is for.
The reference string of the request in the format of "CoverageEligibilityRequest/cd98975b-6cd4-413d-ab65-1fc5eec76762".
Type the reference refers to (e.g. “CoverageEligibilityRequest”).
Outcome of the request processing, if an error occurs it will be marked as “error” othervise it will be marked as “complete”.
Coverage issuer.
Payor ID for the Coverage issuer.
Text alternative for the resource.
Patient insurance information. This includes the Coverage reference, extension for plan name and an array of items containing benefits and authorization details returned from Claim.MD.
The amount of information surfaced here depends on the what the payor supports. Our clearinghouse (Claim.md) performs these eligibility checks, but not all coverages will support real-time eligibility checks. For more information on coverages within Canvas, see this Zendesk article.
Insurance information.
The reference string of the coverage in the format of "Coverage/4a86f580-e192-489a-a9f0-7c915fc67111".
Type the reference refers to (e.g. “Coverage”).
Canvas supports a plan name extension on this resource for read and search interactions.
Reference that defines the content of this object.
The plan name of the insurance.
Array of items containing benefits and authorization details.
Short name for the benefit
Individual or family.
Code defined by a terminology system.
The system url of the coding.
The code of the benefit unit.
The display name of the coding.
Plain text representation of the concept.
In or out of network.
Code defined by a terminology system.
The system url of the coding.
The code of the benefit network.
The display name of the coding.
Plain text representation of the concept.
Benefit Summary.
Benefit classification.
Plain text representation of the concept.
Benefits allowed.
Used for Co-Insurance benefit types.
Benefits allowed.
Used for Co-Payment, Deductible, or Out of Pocket benefit types.
Numerical value (with implicit precision)
Benefits allowed.
Used for Limitations benefit types.
Benefits used.
Used for Deductible or Out of Pocket benefit types.
Numerical value (with implicit precision)
Benefits used.
Used for Limitations benefit types.
Responses
Errors
curl --request GET \ --url 'https://fumage-example.canvasmedical.com/CoverageEligibilityResponse/<id>' \ --header 'Authorization: Bearer <token>' \ --header 'accept: application/json'import requests url = "https://fumage-example.canvasmedical.com/CoverageEligibilityResponse/<id>" headers = { "accept": "application/json", "Authorization": "Bearer <token>" } response = requests.get(url, headers=headers) print(response.text)
{ "resourceType": "CoverageEligibilityResponse", "id": "9ad12f4e-4f35-4f54-8b4f-036516488191", "status": "active", "purpose": [ "benefits" ], "patient": { "reference": "Patient/b41c7cda738d440cb55e0e6cb67499a1", "type": "Patient" }, "created": "2023-09-19T18:16:39.551617+00:00", "request": { "reference": "CoverageEligibilityRequest/d7254641-e363-488c-91fa-b93a6170b9e0", "type": "CoverageEligibilityRequest" }, "outcome": "complete", "insurer": { "identifier": "1111", "display": "Payer ID: 1111" }, "insurance": [ { "extension": [ { "url": "http://schemas.canvasmedical.com/fhir/extensions/active-health-benefit-plan-coverage-description", "valueString": "Humana Gold Plus" } ], "coverage": { "reference": "Coverage/4a86f580-e192-489a-a9f0-7c915fc67111", "type": "Coverage" }, "item": [ { "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Co-Payment" }, "allowedMoney": { "value": 333 } }, { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" } ] }, { "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" }, { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" }, { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" } ] }, { "benefit": [ { "type": { "text": "Benefit Description (Incomplete information)" } } ] }, { "benefit": [ { "type": { "text": "Active Coverage" } } ] }, { "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "benefit": [ { "type": { "text": "Active Coverage" } }, { "type": { "text": "Primary Care Provider (Incomplete information)" } }, { "type": { "text": "Benefit Description (Incomplete information)" } }, { "type": { "text": "Benefit Disclaimer (Incomplete information)" } } ] }, { "name": "Dental Care", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Active Coverage" } } ] }, { "name": "Health Benefit Plan Coverage", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Deductible (Incomplete information)" } }, { "type": { "text": "Deductible" }, "allowedMoney": { "value": 6900 }, "usedMoney": { "value": 0.0 } }, { "type": { "text": "Active Coverage" } }, { "type": { "text": "Out of Pocket (Stop Loss)" }, "allowedMoney": { "value": 6900 }, "usedMoney": { "value": 0.0 } }, { "type": { "text": "Out of Pocket (Stop Loss)" }, "allowedMoney": { "value": 6900 }, "usedMoney": { "value": 0.0 } } ] }, { "name": "Health Benefit Plan Coverage", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "benefit": [ { "type": { "text": "Benefit Description (Incomplete information)" } } ] }, { "name": "Physician Visit - Well", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "benefit": [ { "type": { "text": "Non-Covered (Incomplete information)" } } ] }, { "name": "Professional (Physician) Visit - Office", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" } ] }, { "name": "Professional (Physician) Visit - Office", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "benefit": [ { "type": { "text": "Non-Covered (Incomplete information)" } }, { "type": { "text": "Active Coverage" } } ] } ] } ] }{ "resourceType": "OperationOutcome", "issue": [ { "severity": "error", "code": "unknown", "details": { "text": "Authentication failed" } } ] }{ "resourceType": "OperationOutcome", "issue": [ { "severity": "error", "code": "forbidden", "details": { "text": "Authorization failed" } } ] }{ "resourceType": "OperationOutcome", "issue": [ { "severity": "error", "code": "not-found", "details": { "text": "Unknown CoverageEligibilityResponse resource 'c152eeb7-f204-4e28-acb5-c7e85390b17e'" } } ] }
curl --request GET \ --url 'https://fumage-example.canvasmedical.com/Group?request=CoverageEligibilityRequest/b41c7cda738d440cb55e0e6cb67499a1' \ --header 'Authorization: Bearer <token>' \ --header 'accept: application/json'import requests url = "https://fumage-example.canvasmedical.com/Group?request=CoverageEligibilityRequest/b41c7cda738d440cb55e0e6cb67499a1" headers = { "accept": "application/json", "Authorization": "Bearer <token>" } response = requests.get(url, headers=headers) print(response.text)
{ "resourceType": "Bundle", "type": "searchset", "total": 1, "entry": [ { "resource": { "resourceType": "CoverageEligibilityResponse", "id": "9ad12f4e-4f35-4f54-8b4f-036516488191", "status": "active", "purpose": [ "benefits" ], "patient": { "reference": "Patient/b41c7cda738d440cb55e0e6cb67499a1", "type": "Patient" }, "created": "2023-09-19T18:16:39.551617+00:00", "request": { "reference": "CoverageEligibilityRequest/d7254641-e363-488c-91fa-b93a6170b9e0", "type": "CoverageEligibilityRequest" }, "outcome": "complete", "insurer": { "identifier": "1111", "display": "Payer ID: 1111" }, "insurance": [ { "extension": [ { "url": "http://schemas.canvasmedical.com/fhir/extensions/active-health-benefit-plan-coverage-description", "valueString": "Humana Gold Plus" } ], "coverage": { "reference": "Coverage/4a86f580-e192-489a-a9f0-7c915fc67111", "type": "Coverage" }, "item": [ { "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Co-Payment" }, "allowedMoney": { "value": 333 } }, { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" } ] }, { "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" }, { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" }, { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" } ] }, { "benefit": [ { "type": { "text": "Benefit Description (Incomplete information)" } } ] }, { "benefit": [ { "type": { "text": "Active Coverage" } } ] }, { "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "benefit": [ { "type": { "text": "Active Coverage" } }, { "type": { "text": "Primary Care Provider (Incomplete information)" } }, { "type": { "text": "Benefit Description (Incomplete information)" } }, { "type": { "text": "Benefit Disclaimer (Incomplete information)" } } ] }, { "name": "Dental Care", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Active Coverage" } } ] }, { "name": "Health Benefit Plan Coverage", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Deductible (Incomplete information)" } }, { "type": { "text": "Deductible" }, "allowedMoney": { "value": 6900 }, "usedMoney": { "value": 0.0 } }, { "type": { "text": "Active Coverage" } }, { "type": { "text": "Out of Pocket (Stop Loss)" }, "allowedMoney": { "value": 6900 }, "usedMoney": { "value": 0.0 } }, { "type": { "text": "Out of Pocket (Stop Loss)" }, "allowedMoney": { "value": 6900 }, "usedMoney": { "value": 0.0 } } ] }, { "name": "Health Benefit Plan Coverage", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "benefit": [ { "type": { "text": "Benefit Description (Incomplete information)" } } ] }, { "name": "Physician Visit - Well", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "benefit": [ { "type": { "text": "Non-Covered (Incomplete information)" } } ] }, { "name": "Professional (Physician) Visit - Office", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual", "display": "Individual" } ], "text": "Individual" }, "benefit": [ { "type": { "text": "Co-Insurance" }, "allowedString": "0.0%" } ] }, { "name": "Professional (Physician) Visit - Office", "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in", "display": "In Network" } ], "text": "In Network" }, "benefit": [ { "type": { "text": "Non-Covered (Incomplete information)" } }, { "type": { "text": "Active Coverage" } } ] } ] } ] } } ] }{ "resourceType": "OperationOutcome", "id": "101", "issue": [ { "severity": "error", "code": "invalid", "details": { "text": "Bad request" } } ] }{ "resourceType": "OperationOutcome", "issue": [ { "severity": "error", "code": "unknown", "details": { "text": "Authentication failed" } } ] }{ "resourceType": "OperationOutcome", "issue": [ { "severity": "error", "code": "forbidden", "details": { "text": "Authorization failed" } } ] }