Release 5 Preview #2

Coverageeligibilityresponse-example-benefits-2.xml

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

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

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General Person Primary Coverage with Benefit Details and new insurance (id = "E2502")

<?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"/> 

      <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> 

      <payor> 
        <identifier> 
          <system value="http://www.bindb.com/bin"/> 
          <value value="123456"/> 
        </identifier> 
      </payor> 

      <class> 
        <type> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> 
            <code value="EHCPOL"/> 
          </coding> 
        </type> 
        <value value="CBI35"/> 
        <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="123"/> 
        <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="1"/> 
      </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> 

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.