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

<Coverage xmlns="http://hl7.org/fhir">
  <id value="Coverage1"/>
  <meta>
    <lastUpdated value="2020-10-30T09:48:01.8462752-04:00"/>
    <profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.2.0"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="generated"/>
  </text>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <version value="5.0.0"/>
        <code value="MB"/>
        <display value="Member Number"/>
      </coding>
      <text value="An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier."/>
    </type>
    <system value="https://www.example.com/fhir/memberidentifier"/>
    <value value="88800933501"/>
    <assigner>
      <reference value="Organization/Payer2"/>
      <display value="UPMC Health Plan"/>
    </assigner>
  </identifier>
  <status value="active"/>
  <policyHolder>
    <reference value="Patient/Patient1"/>
  </policyHolder>
  <subscriber>
    <reference value="Patient/Patient1"/>
  </subscriber>
  <subscriberId value="888009335"/>
  <beneficiary>
    <reference value="Patient/Patient1"/>
  </beneficiary>
  <dependent value="01"/>
  <relationship>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
      <code value="self"/>
    </coding>
    <text value="Self"/>
  </relationship>
  <period>
    <start value="2020-01-01"/>
  </period>
  <payor>
    <reference value="Organization/Payer2"/>
    <display value="UPMC Health Plan"/>
  </payor>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="group"/>
        <display value="Group"/>
      </coding>
      <text value="An employee group"/>
    </type>
    <value value="MCHMO1"/>
    <name value="MEDICARE HMO PLAN"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="plan"/>
        <display value="Plan"/>
      </coding>
      <text value="A specific suite of benefits."/>
    </type>
    <value value="GR5"/>
    <name value="GR5-HMO DEDUCTIBLE"/>
  </class>
  <network value="GR5-HMO DEDUCTIBLE"/>
</Coverage>