CoverageEligibilityResponse — Eligibility reply

The insurer replies: yes the patient is covered, here are the benefits, here are the caps, here are the deductibles. Direct counterpart of X12 271.

Purpose

Synchronous or asynchronous reply to CoverageEligibilityRequest. Carries via insurance.item.benefit the detail of covered benefits (category, copay, annual cap, deductible), letting the provider estimate the patient out-of-pocket before care.

Key fields

JSON example

Positive reply with a $25 copay:

{
  "resourceType": "CoverageEligibilityResponse",
  "id": "example",
  "status": "active",
  "purpose": ["benefits"],
  "patient": { "reference": "Patient/example" },
  "created": "2026-05-16",
  "request": { "reference": "CoverageEligibilityRequest/example" },
  "outcome": "complete",
  "insurer": { "reference": "Organization/insurer-bcbs" },
  "insurance": [{
    "coverage": { "reference": "Coverage/example" },
    "inforce": true,
    "benefitPeriod": { "start": "2026-01-01", "end": "2026-12-31" },
    "item": [{
      "category": { "coding": [{ "code": "30", "display": "Health Benefit Plan Coverage" }] },
      "benefit": [{
        "type": { "coding": [{ "code": "copay", "display": "Copayment" }] },
        "allowedMoney": { "value": 25, "currency": "USD" }
      }]
    }]
  }]
}

Common pitfalls

• outcome="complete" but empty insurance: inconsistent — the insurer must provide the benefit detail when completing.
• benefitPeriod missing: the provider does not know whether benefits apply at care time.
• Confusion allowedMoney / usedMoney: allowed = annual cap, used = already consumed. Remaining = allowed - used.

Related resources

• CoverageEligibilityRequest — the request.
• Coverage — detailed coverage.
• Claim / ClaimResponse — next cycle.
• X12 271 — EDI counterpart.

See also: CoverageEligibilityRequest, X12 271.