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

<Coverage xmlns="http://hl7.org/fhir">
  <id value="CoverageDental1"/>
  <meta>
    <lastUpdated value="2021-01-01T14:22:01.0314215+00:00"/>
    <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"/>
      </coding>
    </type>
    <system value="https://www.example.com/fhir/memberidentifier"/>
    <value value="210300002"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <code value="DENTAL"/>
    </coding>
    <text value="dental care policy"/>
  </type>
  <policyHolder>
    <reference value="Patient/Patient2"/>
  </policyHolder>
  <subscriber>
    <reference value="Patient/Patient2"/>
  </subscriber>
  <subscriberId value="10300007"/>
  <beneficiary>
    <reference value="Patient/Patient2"/>
  </beneficiary>
  <dependent value="01"/>
  <relationship>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
      <code value="self"/>
    </coding>
  </relationship>
  <period>
    <start value="2021-01-01"/>
    <end value="2021-12-31"/>
  </period>
  <payor>
    <reference value="Organization/DentalPayer1"/>
  </payor>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="group"/>
      </coding>
      <text value="An employee group"/>
    </type>
    <value value="10300007"/>
    <name value="Transcorp - dental"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="plan"/>
      </coding>
      <text value="Plan"/>
    </type>
    <value value="66783JJT"/>
    <name value="INSURANCE COMPANY XYZ - PRIME"/>
  </class>
  <network value="INSURANCE COMPANY XYZ - PRIME"/>
</Coverage>