CoverageEligibilityRequest — Eligibility check
The provider checks with the insurer the patient's coverage and available benefits. Direct counterpart of X12 270 (HIPAA).
Purpose
Pivot of the pre-service cycle. The provider (clinic, physician) queries the insurer to know: is the patient covered at care time? Which benefits are included? What is the remaining cap? What deductible applies? The response arrives as CoverageEligibilityResponse (X12 271 counterpart).
Key fields
| Field | Type | Cardinality | Role |
|---|---|---|---|
status | code | 1..1 | active, cancelled, draft, entered-in-error. |
purpose | code[] | 1..* | auth-requirements, benefits, discovery, validation. |
patient | Reference(Patient) | 1..1 | Beneficiary. |
created | dateTime | 1..1 | Creation date. |
insurer | Reference(Organization) | 1..1 | Target insurer. |
provider | Reference(Practitioner | PractitionerRole | Organization) | 0..1 | Requesting provider. |
insurance | BackboneElement[] | 0..* | Coverage(s) to query. |
item | BackboneElement[] | 0..* | Specific items (act, drug, device). |
JSON example
Eligibility check for a BCBS patient:
{
"resourceType": "CoverageEligibilityRequest",
"id": "example",
"status": "active",
"purpose": ["validation", "benefits"],
"patient": { "reference": "Patient/example" },
"created": "2026-05-16",
"insurer": { "reference": "Organization/insurer-bcbs" },
"provider": { "reference": "Practitioner/dr-smith" },
"insurance": [{
"focal": true,
"coverage": { "reference": "Coverage/example" }
}]
}Common pitfalls
- No CoverageEligibilityResponse: the operation has no standard timeout; US payers usually mandate < 20s.
- Purpose mis-chosen:
discovery≠benefits. Discovery = "does the patient have any coverage?", Benefits = "which services are covered?". - Coverage missing or invalid: insurance must reference an in-force Coverage.
Related resources
- CoverageEligibilityResponse — insurer reply.
- Coverage — queried coverage.
- Claim — reimbursement claim (next cycle).
- X12 270 — North-American EDI counterpart.
See also: CoverageEligibilityResponse, X12 270.