Release 5 Preview #2

Coverageeligibilityresponse-example-benefits-2.json

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

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

General Person Primary Coverage with Benefit Details and new insurance

{
  "resourceType": "CoverageEligibilityResponse",
  "id": "E2502",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the CoverageEligibilityResponse.</div>"
  },
  "contained": [
    {
      "resourceType": "Coverage",
      "id": "coverage-1",
      "identifier": [
        {
          "system": "http://benefitsinc.com/certificate",
          "value": "12345"
        }
      ],
      "status": "active",
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code": "EHCPOL"
          }
        ]
      },
      "subscriber": {
        "reference": "Patient/f201"
      },
      "beneficiary": {
        "reference": "Patient/f201"
      },
      "dependent": "1",
      "relationship": {
        "coding": [
          {
            "code": "self"
          }
        ]
      },
      "payor": [
        {
          "identifier": {
            "system": "http://www.bindb.com/bin",
            "value": "123456"
          }
        }
      ],
      "class": [
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
                "code": "EHCPOL"
              }
            ]
          },
          "value": "CBI35",
          "name": "Corporate Baker's Inc. Plan#35"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "subplan"
              }
            ]
          },
          "value": "123",
          "name": "Trainee Part-time Benefits"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "sequence"
              }
            ]
          },
          "value": "1"
        }
      ]
    }
  ],
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/coverageeligibilityresponse",
      "value": "8812342"
    }
  ],
  "status": "active",
  "purpose": [
    "validation",
    "benefits"
  ],
  "patient": {
    "reference": "Patient/f201"
  },
  "created": "2014-09-16",
  "requestor": {
    "identifier": {
      "system": "http://national.org/clinic",
      "value": "OR1234"
    }
  },
  "request": {
    "reference": "http://www.BenefitsInc.com/fhir/coverageeligibilityrequest/225476332405"
  },
  "outcome": "complete",
  "disposition": "Policy is currently in-force.",
  "insurer": {
    "reference": "Organization/2"
  },
  "insurance": [
    {
      "coverage": {
        "reference": "#coverage-1"
      },
      "inforce": true,
      "item": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "30",
                "display": "Health Benefit Plan Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
                "code": "in"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code": "individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-term",
                "code": "annual"
              }
            ]
          },
          "benefit": [
            {
              "type": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 500000,
                "currency": "USD"
              },
              "usedMoney": {
                "value": 3748.00,
                "currency": "USD"
              }
            },
            {
              "type": {
                "coding": [
                  {
                    "code": "copay-maximum"
                  }
                ]
              },
              "allowedMoney": {
                "value": 100,
                "currency": "USD"
              }
            },
            {
              "type": {
                "coding": [
                  {
                    "code": "copay-percent"
                  }
                ]
              },
              "allowedUnsignedInt": 20
            }
          ]
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "69",
                "display": "Maternity"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
                "code": "in"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code": "individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-term",
                "code": "annual"
              }
            ]
          },
          "benefit": [
            {
              "type": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 15000,
                "currency": "USD"
              }
            }
          ]
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "F3",
                "display": "Dental Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
                "code": "in"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code": "individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-term",
                "code": "annual"
              }
            ]
          },
          "benefit": [
            {
              "type": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 2000,
                "currency": "USD"
              }
            }
          ]
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "F6",
                "display": "Vision Coverage"
              }
            ]
          },
          "excluded": true,
          "name": "Vision",
          "description": "Vision products and services such as exams, glasses and contact lenses."
        }
      ]
    }
  ],
  "form": {
    "coding": [
      {
        "system": "http://national.org/form",
        "code": "ELRSP/2017/01"
      }
    ]
  }
}

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.