Release 4

Coverage-example.xml

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Patient, RelatedPerson

Raw XML (canonical form + also see XML Format Specification)

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General Person Primary Coverage Example (id = "9876B1")

<?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"/> 

  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> 
      <code value="EHCPOL"/> 
      <display value="extended healthcare"/> 
    </coding> 
  </type> 

  <policyHolder> 
    <reference value="http://benefitsinc.com/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> 

  <payor> 
    <reference value="Organization/2"/> 
  </payor> 

  <!--   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="CB135"/> 
    <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="123"/> 
    <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="B37FC"/> 
    <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="P7"/> 
    <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="SILVER"/> 
    <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="Tier2"/> 
    <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="9"/> 
  </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> 
    <value value="MDF12345"/>  <!--   member id used when submitting pharmacy claims   -->
  </class> 

  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="rxbin"/> 
      </coding> 
    </type> 
    <value value="987654"/>  <!--   the pharmacy processor BIN number used when submitting pharmacy claims   -->
  </class> 

  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="rxgroup"/> 
      </coding> 
    </type> 
    <value value="M35PT"/>  <!--   group used when submitting pharmacy claims   -->
  </class> 

  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="rxpcn"/> 
      </coding> 
    </type> 
    <value value="234516"/>  <!--   the PCN number used when submitting pharmacy claims   -->
  </class> 

  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="sequence"/> 
      </coding> 
    </type> 
    <value value="9"/>  <!--   the sequence number for a short-term continuance of the coverage   -->
  </class> 

</Coverage> 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.