<?xml version="1.0" encoding="UTF-8"?>

<Coverage xmlns="http://hl7.org/fhir">
  <id value="9876B1"/>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the coverage</div>
  </text>
  <identifier>
    <system value="http://benefitsinc.com/certificate"/>
    <value value="12345"/>
  </identifier>
  <status value="active"/>
  <kind value="insurance"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <code value="EHCPOL"/>
      <display value="extended healthcare"/>
    </coding>
  </type>
  <policyHolder>
    <reference value="http://benefits.example.org/FHIR/Organization/CBI35"/>
  </policyHolder>
  <subscriber>
    <reference value="Patient/4"/>
  </subscriber>
  <beneficiary>
    <reference value="Patient/4"/>
  </beneficiary>
  <dependent value="0"/>
  <relationship>
    <coding>
      <code value="self"/>
    </coding>
  </relationship>
  <period>
    <start value="2011-05-23"/>
    <end value="2012-05-23"/>
  </period>
  <insurer>
    <reference value="Organization/2"/>
  </insurer>
  <!--  The repeating 'class' element is proposed to replace the 'grouping' element  -->
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="group"/>
      </coding>
    </type>
    <value>
      <value value="CB135"/>
    </value>
    <name value="Corporate Baker's Inc. Local #35"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="subgroup"/>
      </coding>
    </type>
    <value>
      <value value="123"/>
    </value>
    <name value="Trainee Part-time Benefits"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="plan"/>
      </coding>
    </type>
    <value>
      <value value="B37FC"/>
    </value>
    <name value="Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="subplan"/>
      </coding>
    </type>
    <value>
      <value value="P7"/>
    </value>
    <name value="Includes afterlife benefits"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="class"/>
      </coding>
    </type>
    <value>
      <value value="SILVER"/>
    </value>
    <name value="Silver: Family Plan spouse only"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="subclass"/>
      </coding>
    </type>
    <value>
      <value value="Tier2"/>
    </value>
    <name value="Low deductable, max $20 copay"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="sequence"/>
      </coding>
    </type>
    <value>
      <value value="9"/>
    </value>
  </class>
  <!--  the following RX class values may be used when pharmacy claims under this coverage are sent to a pharmacy claim only processor  -->
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="rxid"/>
      </coding>
    </type>
    <!--  member id used when submitting pharmacy claims  -->
    <value>
      <value value="MDF12345"/>
    </value>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="rxbin"/>
      </coding>
    </type>
    <!--  the pharmacy processor BIN number used when submitting pharmacy claims  -->
    <value>
      <value value="987654"/>
    </value>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="rxgroup"/>
      </coding>
    </type>
    <!--  group used when submitting pharmacy claims  -->
    <value>
      <value value="M35PT"/>
    </value>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="rxpcn"/>
      </coding>
    </type>
    <!--  the PCN number used when submitting pharmacy claims  -->
    <value>
      <value value="234516"/>
    </value>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="sequence"/>
      </coding>
    </type>
    <!--  the sequence number for a short-term continuance of the coverage  -->
    <value>
      <value value="9"/>
    </value>
  </class>
</Coverage>