HL7 Vietnam VN Core FHIR Implementation Guide

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam
0.6.0 - Draft for Community Review Viet Nam cờ

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam - Draft for Community Review (v0.6.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Hồ sơ tài nguyên: Kết quả tra cứu quyền lợi BHYT VN Core — VN Core Coverage Eligibility Response Profile

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-coverage-eligibility-response Phiên bản: 0.6.0
Computable Name: VNCoreCoverageEligibilityResponse

Bản quyền/Pháp lý: Căn cứ pháp lý Việt Nam: Luật 51/2024/QH15 ngày 27/11/2024; NĐ 188/2025/NĐ-CP; NĐ 164/2025/NĐ-CP ngày 29/06/2025; QĐ 3176/QĐ-BYT ngày 29/10/2024.

Profile CoverageEligibilityResponse — phản hồi từ Cổng giám định BHYT cho yêu cầu tra cứu thẻ: hiệu lực thẻ tại thời điểm tra cứu (insurance.inforce), quyền lợi và mức hưởng. Cặp với VNCoreCoverageEligibilityRequest. Căn cứ:

  • Luật 51/2024/QH15 — 27/11/2024 — sửa đổi Luật BHYT, hiệu lực 01/7/2025
  • NĐ 188/2025/NĐ-CP — ban hành 01/7/2025, hiệu lực 15/8/2025 — quyền lợi và mức hưởng BHYT
  • NĐ 164/2025/NĐ-CP — 29/6/2025 — giao dịch điện tử trong lĩnh vực BHXH
  • QĐ 3176/QĐ-BYT — 29/10/2024 — chuẩn dữ liệu KCB phục vụ BHXH

Usages:

You can also check for usages in the FHIR IG Statistics

Các dạng xem hình thức của nội dung hồ sơ

Mô tả profile, differential, snapshot và các biểu diễn liên quan.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 0..* Identifier Mã giao dịch phản hồi — đối soát với request của cơ sở KCB
... purpose SΣ 1..* code Mục đích tra cứu (khớp request): validation | benefits | ...
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
... patient SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Intended recipient of products and services
... created SΣ 1..1 dateTime Thời điểm tạo phản hồi
... request SΣ 1..1 Reference(Yêu cầu tra cứu quyền lợi BHYT VN Core — VN Core Coverage Eligibility Request Profile) Yêu cầu tra cứu tương ứng
... outcome SΣ 1..1 code queued | complete | error | partial — kết quả xử lý của Cổng BHYT
Binding: ClaimProcessingCodes (required): The outcome of the processing.
... insurer SΣ 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH phản hồi
... insurance S 0..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage SΣ 1..1 Reference(Thẻ BHYT VN Core — VN Core Coverage Profile) Insurance information
.... inforce S 0..1 boolean Thẻ BHYT còn hiệu lực tại thời điểm tra cứu (true/false)
.... item SC 0..* BackboneElement Chi tiết quyền lợi/mức hưởng BHYT khi purpose=benefits (mỗi nhóm quyền lợi 1 item)
Constraints: ces-1
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... benefit S 0..* BackboneElement Mức hưởng theo loại quyền lợi (vd tỷ lệ %, trần thanh toán)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
ces-1 error CoverageEligibilityResponse.insurance.item SHALL contain a category or a billcode but not both. category.exists() xor productOrService.exists()
dom-2 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice CoverageEligibilityResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... identifier S 0..* Identifier Mã giao dịch phản hồi — đối soát với request của cơ sở KCB
... status S 1..1 code active | cancelled | draft | entered-in-error
... purpose S 1..* code Mục đích tra cứu (khớp request): validation | benefits | ...
... created S 1..1 dateTime Thời điểm tạo phản hồi
... request S 1..1 Reference(Yêu cầu tra cứu quyền lợi BHYT VN Core — VN Core Coverage Eligibility Request Profile) Yêu cầu tra cứu tương ứng
... outcome S 1..1 code queued | complete | error | partial — kết quả xử lý của Cổng BHYT
... insurer S 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH phản hồi
... insurance S 0..* BackboneElement Patient insurance information
.... coverage S 1..1 Reference(Thẻ BHYT VN Core — VN Core Coverage Profile) Insurance information
.... inforce S 0..1 boolean Thẻ BHYT còn hiệu lực tại thời điểm tra cứu (true/false)
.... item S 0..* BackboneElement Chi tiết quyền lợi/mức hưởng BHYT khi purpose=benefits (mỗi nhóm quyền lợi 1 item)
..... benefit S 0..* BackboneElement Mức hưởng theo loại quyền lợi (vd tỷ lệ %, trần thanh toán)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 0..* Identifier Mã giao dịch phản hồi — đối soát với request của cơ sở KCB
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... purpose SΣ 1..* code Mục đích tra cứu (khớp request): validation | benefits | ...
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
... patient SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Intended recipient of products and services
... serviced[x] 0..1 Estimated date or dates of service
.... servicedDate date
.... servicedPeriod Period
... created SΣ 1..1 dateTime Thời điểm tạo phản hồi
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request SΣ 1..1 Reference(Yêu cầu tra cứu quyền lợi BHYT VN Core — VN Core Coverage Eligibility Request Profile) Yêu cầu tra cứu tương ứng
... outcome SΣ 1..1 code queued | complete | error | partial — kết quả xử lý của Cổng BHYT
Binding: ClaimProcessingCodes (required): The outcome of the processing.
... disposition 0..1 string Disposition Message
... insurer SΣ 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH phản hồi
... insurance S 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage SΣ 1..1 Reference(Thẻ BHYT VN Core — VN Core Coverage Profile) Insurance information
.... inforce S 0..1 boolean Thẻ BHYT còn hiệu lực tại thời điểm tra cứu (true/false)
.... benefitPeriod 0..1 Period When the benefits are applicable
.... item SC 0..* BackboneElement Chi tiết quyền lợi/mức hưởng BHYT khi purpose=benefits (mỗi nhóm quyền lợi 1 item)
Constraints: ces-1
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Excluded from the plan
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
..... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
..... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
..... benefit S 0..* BackboneElement Mức hưởng theo loại quyền lợi (vd tỷ lệ %, trần thanh toán)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
...... allowed[x] 0..1 Benefits allowed
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
...... used[x] 0..1 Benefits used
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.network Base example Network Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.authorizationSupporting Base example CoverageEligibilityResponse Auth Support Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​form Base example Forms 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​error.code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
ces-1 error CoverageEligibilityResponse.insurance.item SHALL contain a category or a billcode but not both. category.exists() xor productOrService.exists()
dom-2 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice CoverageEligibilityResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Dạng xem phần tử chính

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 0..* Identifier Mã giao dịch phản hồi — đối soát với request của cơ sở KCB
... purpose SΣ 1..* code Mục đích tra cứu (khớp request): validation | benefits | ...
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
... patient SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Intended recipient of products and services
... created SΣ 1..1 dateTime Thời điểm tạo phản hồi
... request SΣ 1..1 Reference(Yêu cầu tra cứu quyền lợi BHYT VN Core — VN Core Coverage Eligibility Request Profile) Yêu cầu tra cứu tương ứng
... outcome SΣ 1..1 code queued | complete | error | partial — kết quả xử lý của Cổng BHYT
Binding: ClaimProcessingCodes (required): The outcome of the processing.
... insurer SΣ 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH phản hồi
... insurance S 0..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage SΣ 1..1 Reference(Thẻ BHYT VN Core — VN Core Coverage Profile) Insurance information
.... inforce S 0..1 boolean Thẻ BHYT còn hiệu lực tại thời điểm tra cứu (true/false)
.... item SC 0..* BackboneElement Chi tiết quyền lợi/mức hưởng BHYT khi purpose=benefits (mỗi nhóm quyền lợi 1 item)
Constraints: ces-1
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... benefit S 0..* BackboneElement Mức hưởng theo loại quyền lợi (vd tỷ lệ %, trần thanh toán)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
ces-1 error CoverageEligibilityResponse.insurance.item SHALL contain a category or a billcode but not both. category.exists() xor productOrService.exists()
dom-2 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice CoverageEligibilityResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Dạng xem Differential

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... identifier S 0..* Identifier Mã giao dịch phản hồi — đối soát với request của cơ sở KCB
... status S 1..1 code active | cancelled | draft | entered-in-error
... purpose S 1..* code Mục đích tra cứu (khớp request): validation | benefits | ...
... created S 1..1 dateTime Thời điểm tạo phản hồi
... request S 1..1 Reference(Yêu cầu tra cứu quyền lợi BHYT VN Core — VN Core Coverage Eligibility Request Profile) Yêu cầu tra cứu tương ứng
... outcome S 1..1 code queued | complete | error | partial — kết quả xử lý của Cổng BHYT
... insurer S 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH phản hồi
... insurance S 0..* BackboneElement Patient insurance information
.... coverage S 1..1 Reference(Thẻ BHYT VN Core — VN Core Coverage Profile) Insurance information
.... inforce S 0..1 boolean Thẻ BHYT còn hiệu lực tại thời điểm tra cứu (true/false)
.... item S 0..* BackboneElement Chi tiết quyền lợi/mức hưởng BHYT khi purpose=benefits (mỗi nhóm quyền lợi 1 item)
..... benefit S 0..* BackboneElement Mức hưởng theo loại quyền lợi (vd tỷ lệ %, trần thanh toán)

doco Documentation for this format

Dạng xem SnapshotView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CoverageEligibilityResponse 0..* CoverageEligibilityResponse CoverageEligibilityResponse resource
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 0..* Identifier Mã giao dịch phản hồi — đối soát với request của cơ sở KCB
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... purpose SΣ 1..* code Mục đích tra cứu (khớp request): validation | benefits | ...
Binding: EligibilityResponsePurpose (required): A code specifying the types of information being requested.
... patient SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Intended recipient of products and services
... serviced[x] 0..1 Estimated date or dates of service
.... servicedDate date
.... servicedPeriod Period
... created SΣ 1..1 dateTime Thời điểm tạo phản hồi
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the request
... request SΣ 1..1 Reference(Yêu cầu tra cứu quyền lợi BHYT VN Core — VN Core Coverage Eligibility Request Profile) Yêu cầu tra cứu tương ứng
... outcome SΣ 1..1 code queued | complete | error | partial — kết quả xử lý của Cổng BHYT
Binding: ClaimProcessingCodes (required): The outcome of the processing.
... disposition 0..1 string Disposition Message
... insurer SΣ 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH phản hồi
... insurance S 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... coverage SΣ 1..1 Reference(Thẻ BHYT VN Core — VN Core Coverage Profile) Insurance information
.... inforce S 0..1 boolean Thẻ BHYT còn hiệu lực tại thời điểm tra cứu (true/false)
.... benefitPeriod 0..1 Period When the benefits are applicable
.... item SC 0..* BackboneElement Chi tiết quyền lợi/mức hưởng BHYT khi purpose=benefits (mỗi nhóm quyền lợi 1 item)
Constraints: ces-1
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision etc.
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... provider 0..1 Reference(Practitioner | PractitionerRole) Performing practitioner
..... excluded 0..1 boolean Excluded from the plan
..... name 0..1 string Short name for the benefit
..... description 0..1 string Description of the benefit or services covered
..... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
..... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
..... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
..... benefit S 0..* BackboneElement Mức hưởng theo loại quyền lợi (vd tỷ lệ %, trần thanh toán)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
...... allowed[x] 0..1 Benefits allowed
....... allowedUnsignedInt unsignedInt
....... allowedString string
....... allowedMoney Money
...... used[x] 0..1 Benefits used
....... usedUnsignedInt unsignedInt
....... usedString string
....... usedMoney Money
..... authorizationRequired 0..1 boolean Authorization required flag
..... authorizationSupporting 0..* CodeableConcept Type of required supporting materials
Binding: CoverageEligibilityResponseAuthSupportCodes (example): Type of supporting information to provide with a preauthorization.
..... authorizationUrl 0..1 uri Preauthorization requirements endpoint
... preAuthRef 0..1 string Preauthorization reference
... form 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The error codes for adjudication processing.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CoverageEligibilityResponse.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​purpose Base required EligibilityResponsePurpose 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.network Base example Network Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.benefit.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​insurance.item.authorizationSupporting Base example CoverageEligibilityResponse Auth Support Codes 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​form Base example Forms 📍4.0.1 FHIR Std.
CoverageEligibilityResponse.​error.code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
ces-1 error CoverageEligibilityResponse.insurance.item SHALL contain a category or a billcode but not both. category.exists() xor productOrService.exists()
dom-2 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error CoverageEligibilityResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error CoverageEligibilityResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice CoverageEligibilityResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

 

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