Eligibility Mapping Rules

XES Module for FHIR uses segments of EDI eligibility transactions to create FHIR resources. The following table demonstrates how a transaction segment is used to create a corresponding FHIR resource.

Eligibility Request

FHIR Resource	EDI 270 Segment	Details
Patient	Loop 2100C for Subscriber Loop 2100D for Dependent
RelatedPerson	2110C	Only when a patient is Dependent.
Coverage	-	Refers to a Patient and RelatedPerson when a patient is Dependent.
CoverageEligibilityRequest	Loop 2110C for Subscriber Loop 2110D for Dependent
Organization (type=ins)	Loop 2000A	Defines the type of Organization. XES Module for FHIR supports only two types: ins – insurer prov - provider
Organization (type=prov) Practitioner	Loop 2000B	Defines the type of Organization. XES Module for FHIR supports only two types: ins – insurer prov - provider
Communication	ISA	Carries the EDI file as payload.

Eligibility Response

FHIR Resource	271	Details
Patient	Loop 2100C for Subscriber Loop 2100D for Dependent
RelatedPerson	2110C	Only when a patient is Dependent.
Coverage	-	Refers to a Patient and RelatedPerson when a patient is Dependent.
CoverageEligibilityResponse	Loop 2110C for Subscriber Loop 2110D for Dependent
Organization (type=ins)	Loop 2000A	Defines a type of Organization. XES Module for FHIR supports only two types: ins – insurer prov - provider
Organization (type=prov) Practitioner	Loop 2000B	Type defines the type of Organization. XES Module for FHIR supports only two types: ins – insurer prov - provider
Communication	ISA segment	Carries the EDI file as payload.