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

<Coverage xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <meta>
    <profile value="http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage"/>
  </meta>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource "example" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-qicore-coverage.html">QICoreCoverage</a></p></div><p><b>identifier</b>: id: 12345</p><p><b>status</b>: active</p><p><b>type</b>: Other Private Insurance <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-SOPT.html">Source of Payment Typology</a>#59)</span></p><p><b>policyHolder</b>: <a href="Patient-example.html">Patient/example</a> " CHALMERS"</p><p><b>subscriber</b>: <a href="Patient-example.html">Patient/example</a> " CHALMERS"</p><p><b>beneficiary</b>: <a href="Patient-example.html">Patient/example</a> " CHALMERS"</p><p><b>dependent</b>: 0</p><p><b>relationship</b>: Self <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-subscriber-relationship.html">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2011-05-23 --&gt; 2012-05-23</p><p><b>payor</b>: <a href="Organization-example.html">Organization/example</a> "Health Level Seven International"</p><p><b>order</b>: 9</p></div>
  </text>
  <identifier>
    <system value="http://benefitsinc.com/certificate"/>
    <value value="12345"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="https://nahdo.org/sopt"/>
      <code value="59"/>
      <display value="Other Private Insurance"/>
    </coding>
  </type>
  <policyHolder>
    <reference value="Patient/example"/>
  </policyHolder>
  <subscriber>
    <reference value="Patient/example"/>
  </subscriber>
  <beneficiary>
    <reference value="Patient/example"/>
  </beneficiary>
  <dependent value="0"/>
  <relationship>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
      <code value="self"/>
    </coding>
  </relationship>
  <period>
    <start value="2011-05-23"/>
    <end value="2012-05-23"/>
  </period>
  <payor>
    <reference value="Organization/example"/>
  </payor>
<!--  No longer part of the Coverage resource in R4, not clear how to represent this in the R4 resource  -->
<!-- grouping>
    <group value="CBI35"/>
    <groupDisplay value="Corporate Baker's Inc. Local #35"/>
    <subGroup value="123"/>
    <subGroupDisplay value="Trainee Part-time Benefits"/>
    <plan value="B37FC"/>
    <planDisplay value="Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"/>
    <subPlan value="P7"/>
    <subPlanDisplay value="Includes afterlife benefits"/>
    <class value="SILVER"/>
    <classDisplay value="Silver: Family Plan spouse only"/>
    <subClass value="Tier2"/>
    <subClassDisplay value="Low deductable, max $20 copay"/>
  </grouping -->
  <order value="9"/>
</Coverage>