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

<CoverageEligibilityResponse xmlns="http://hl7.org/fhir">
  <id value="E2502"/>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the CoverageEligibilityResponse.</div>
  </text>
  <contained>
    <Coverage>
      <id value="coverage-1"/>
      <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"/>
        </coding>
      </type>
      <subscriber>
        <reference value="Patient/f201"/>
      </subscriber>
      <beneficiary>
        <reference value="Patient/f201"/>
      </beneficiary>
      <dependent value="1"/>
      <relationship>
        <coding>
          <code value="self"/>
        </coding>
      </relationship>
      <insurer>
        <identifier>
          <system value="http://www.bindb.com/bin"/>
          <value value="123456"/>
        </identifier>
      </insurer>
      <class>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
            <code value="EHCPOL"/>
          </coding>
        </type>
        <value>
          <value value="CBI35"/>
        </value>
        <name value="Corporate Baker's Inc. Plan#35"/>
      </class>
      <class>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
            <code value="subplan"/>
          </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="sequence"/>
          </coding>
        </type>
        <value>
          <value value="1"/>
        </value>
      </class>
    </Coverage>
  </contained>
  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/coverageeligibilityresponse"/>
    <value value="8812342"/>
  </identifier>
  <status value="active"/>
  <purpose value="validation"/>
  <purpose value="benefits"/>
  <patient>
    <reference value="Patient/f201"/>
  </patient>
  <created value="2014-09-16"/>
  <requestor>
    <identifier>
      <system value="http://national.org/clinic"/>
      <value value="OR1234"/>
    </identifier>
  </requestor>
  <request>
    <reference value="http://www.BenefitsInc.com/fhir/coverageeligibilityrequest/225476332405"/>
  </request>
  <outcome value="complete"/>
  <disposition value="Policy is currently in-force."/>
  <insurer>
    <reference value="Organization/2"/>
  </insurer>
  <insurance>
    <coverage>
      <reference value="#coverage-1"/>
    </coverage>
    <inforce value="true"/>
    <item>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
          <code value="30"/>
          <display value="Health Benefit Plan Coverage"/>
        </coding>
      </category>
      <network>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
          <code value="in"/>
        </coding>
      </network>
      <unit>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
          <code value="individual"/>
        </coding>
      </unit>
      <term>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
          <code value="annual"/>
        </coding>
      </term>
      <benefit>
        <type>
          <coding>
            <code value="benefit"/>
          </coding>
        </type>
        <allowedMoney>
          <value value="500000"/>
          <currency value="USD"/>
        </allowedMoney>
        <usedMoney>
          <value value="3748.00"/>
          <currency value="USD"/>
        </usedMoney>
      </benefit>
      <benefit>
        <type>
          <coding>
            <code value="copay-maximum"/>
          </coding>
        </type>
        <allowedMoney>
          <value value="100"/>
          <currency value="USD"/>
        </allowedMoney>
      </benefit>
      <benefit>
        <type>
          <coding>
            <code value="copay-percent"/>
          </coding>
        </type>
        <allowedUnsignedInt value="20"/>
      </benefit>
    </item>
    <item>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
          <code value="69"/>
          <display value="Maternity"/>
        </coding>
      </category>
      <network>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
          <code value="in"/>
        </coding>
      </network>
      <unit>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
          <code value="individual"/>
        </coding>
      </unit>
      <term>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
          <code value="annual"/>
        </coding>
      </term>
      <benefit>
        <type>
          <coding>
            <code value="benefit"/>
          </coding>
        </type>
        <allowedMoney>
          <value value="15000"/>
          <currency value="USD"/>
        </allowedMoney>
      </benefit>
    </item>
    <item>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
          <code value="F3"/>
          <display value="Dental Coverage"/>
        </coding>
      </category>
      <network>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
          <code value="in"/>
        </coding>
      </network>
      <unit>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
          <code value="individual"/>
        </coding>
      </unit>
      <term>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
          <code value="annual"/>
        </coding>
      </term>
      <benefit>
        <type>
          <coding>
            <code value="benefit"/>
          </coding>
        </type>
        <allowedMoney>
          <value value="2000"/>
          <currency value="USD"/>
        </allowedMoney>
      </benefit>
    </item>
    <item>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
          <code value="F6"/>
          <display value="Vision Coverage"/>
        </coding>
      </category>
      <excluded value="true"/>
      <!--  this benefit category is not covered under the plan  -->
      <name value="Vision"/>
      <description value="Vision products and services such as exams, glasses and contact lenses."/>
    </item>
  </insurance>
  <form>
    <coding>
      <system value="http://national.org/form"/>
      <code value="ELRSP/2017/01"/>
    </coding>
  </form>
</CoverageEligibilityResponse>