CARIN Digital Insurance Card
2.0.0 - STU 2.0
CARIN Digital Insurance Card
2.0.0 - STU 2.0
CARIN Digital Insurance Card, published by HL7 International / Payer/Provider Information Exchange Work Group. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-digital-insurance-card/ and changes regularly. See the Directory of published versions
| Page standards status: Informative |
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:InsurancePlan ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "SBCExampleHMO"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "extensions" ] ; fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InsurancePlan SBCExampleHMO</b></p><a name=\"SBCExampleHMO\"> </a><a name=\"hcSBCExampleHMO\"> </a><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\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-sbc-insurance-plan.html\">SBC Insurance Plan Profile</a></p></div><blockquote><p><b>SBC Metadata Extension</b></p><ul><li>sbcVersionDate: 2021-01-01</li><li>minimumEssentialCoverage: true</li><li>minimumValue: true</li></ul></blockquote><blockquote><p><b>Excluded Services Extension</b></p><p><b>serviceType</b>: <span title=\"Codes:\">Cosmetic surgery</span></p><p><b>description</b>: Services for cosmetic purposes are not covered</p><blockquote><p><b>url</b></p>service</blockquote><p><b>serviceType</b>: <span title=\"Codes:\">Weight loss programs</span></p><p><b>description</b>: Weight loss programs except when medically necessary</p><blockquote><p><b>url</b></p>service</blockquote></blockquote><p><b>identifier</b>: <code>https://www.cms.gov/CCIIO/Resources/Data-Resources/hios</code>/12345CA0010001-01</p><p><b>status</b>: Active</p><p><b>name</b>: Sample Health HMO Gold Plan</p><p><b>period</b>: 2025-01-01 --> 2025-12-31</p><p><b>ownedBy</b>: <a href=\"Organization-ExampleIssuerOrg.html\">Sample Health Insurance Company</a></p><p><b>administeredBy</b>: <a href=\"Organization-ExampleIssuerOrg.html\">Organization Sample Health Insurance Company</a></p><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">General Questions</span></p><p><b>telecom</b>: ph: 1-800-123-4567, <a href=\"https://www.samplehealth.com\">https://www.samplehealth.com</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Uniform Glossary</span></p><p><b>telecom</b>: <a href=\"https://www.healthcare.gov/sbc-glossary/\">https://www.healthcare.gov/sbc-glossary/</a></p></blockquote><blockquote><p><b>coverage</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}\">health insurance plan policy</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category preventive-care}\">Preventive Care/Screening/Immunization</span></p><p><b>requirement</b>: No prior authorization required for in-network preventive services</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}\">Primary Care Visit</span></p><p><b>requirement</b>: No referral required</p></blockquote><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Limited to network specialists only; out-of-network not covered except in emergencies</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}\">Specialist Visit</span></p><p><b>requirement</b>: Referral required from primary care physician</p></blockquote><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Copay waived if admitted to hospital</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}\">Emergency Room Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}\">Hospital Inpatient Care</span></p><p><b>requirement</b>: Prior authorization required for non-emergency admissions</p></blockquote></blockquote><blockquote><p><b>plan</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type HMO}\">Health Maintenance Organization (HMO)</span></p><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:\">Individual Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>1500</td><td>United States dollar</td></tr></table><p><b>comment</b>: Individual in-network deductible</p></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:\">Family Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>3000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:\">Individual Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>6000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:\">Family Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>12000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category preventive-care}\">Preventive Care/Screening/Immunization</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category preventive-care}\">Preventive Care/Screening/Immunization</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">No charge</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 0 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}\">Primary Care Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}\">Primary Care Visit</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 25 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}\">Specialist Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}\">Specialist Visit</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 50 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}\">Emergency Room Care</span></p><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Copay waived if admitted</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}\">Emergency Room Care</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 350 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 350 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category generic-drugs}\">Generic Drugs</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category generic-drugs}\">Generic Drugs</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 10 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}\">Hospital Inpatient Care</span></p><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Prior authorization required</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}\">Hospital Inpatient Care</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 20 %</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:\">Not covered</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 0 %</p></blockquote></blockquote></blockquote></blockquote></div>"^^rdf:XMLLiteral ] ] ; # fhir:extension ( [ ( fhir:extension [ fhir:url [ fhir:v "sbcVersionDate"^^xsd:anyURI ; fhir:l fhir:sbcVersionDate ] ; fhir:value [ a fhir:Date ; fhir:v "2021-01-01"^^xsd:date ] ] [ fhir:url [ fhir:v "minimumEssentialCoverage"^^xsd:anyURI ; fhir:l fhir:minimumEssentialCoverage ] ; fhir:value [ a fhir:Boolean ; fhir:v true ] ] [ fhir:url [ fhir:v "minimumValue"^^xsd:anyURI ; fhir:l fhir:minimumValue ] ; fhir:value [ a fhir:Boolean ; fhir:v true ] ] ) ; fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata> ] ] [ ( fhir:extension [ ( fhir:extension [ fhir:url [ fhir:v "serviceType"^^xsd:anyURI ; fhir:l fhir:serviceType ] ; fhir:value [ a fhir:CodeableConcept ; fhir:text [ fhir:v "Cosmetic surgery" ] ] ] [ fhir:url [ fhir:v "description"^^xsd:anyURI ; fhir:l fhir:description ] ; fhir:value [ a fhir:String ; fhir:v "Services for cosmetic purposes are not covered" ] ] ) ; fhir:url [ fhir:v "service"^^xsd:anyURI ; fhir:l fhir:service ] ] [ ( fhir:extension [ fhir:url [ fhir:v "serviceType"^^xsd:anyURI ; fhir:l fhir:serviceType ] ; fhir:value [ a fhir:CodeableConcept ; fhir:text [ fhir:v "Weight loss programs" ] ] ] [ fhir:url [ fhir:v "description"^^xsd:anyURI ; fhir:l fhir:description ] ; fhir:value [ a fhir:String ; fhir:v "Weight loss programs except when medically necessary" ] ] ) ; fhir:url [ fhir:v "service"^^xsd:anyURI ; fhir:l fhir:service ] ] ) ; fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services> ] ] ) ; # fhir:identifier ( [ fhir:system [ fhir:v "https://www.cms.gov/CCIIO/Resources/Data-Resources/hios"^^xsd:anyURI ; fhir:l <https://www.cms.gov/CCIIO/Resources/Data-Resources/hios> ] ; fhir:value [ fhir:v "12345CA0010001-01" ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:name [ fhir:v "Sample Health HMO Gold Plan"] ; # fhir:period [ fhir:start [ fhir:v "2025-01-01"^^xsd:date ] ; fhir:end [ fhir:v "2025-12-31"^^xsd:date ] ] ; # fhir:ownedBy [ fhir:l fhir:Organization/ExampleIssuerOrg ; fhir:reference [ fhir:v "Organization/ExampleIssuerOrg" ] ; fhir:display [ fhir:v "Sample Health Insurance Company" ] ] ; # fhir:administeredBy [ fhir:l fhir:Organization/ExampleIssuerOrg ; fhir:reference [ fhir:v "Organization/ExampleIssuerOrg" ] ] ; # fhir:contact ( [ fhir:purpose [ fhir:text [ fhir:v "General Questions" ] ] ; ( fhir:telecom [ fhir:system [ fhir:v "phone" ] ; fhir:value [ fhir:v "1-800-123-4567" ] ] [ fhir:system [ fhir:v "url" ] ; fhir:value [ fhir:v "https://www.samplehealth.com" ] ] ) ] [ fhir:purpose [ fhir:text [ fhir:v "Uniform Glossary" ] ] ; ( fhir:telecom [ fhir:system [ fhir:v "url" ] ; fhir:value [ fhir:v "https://www.healthcare.gov/sbc-glossary/" ] ] ) ] ) ; # fhir:coverage ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/v3-ActCode> ] ; fhir:code [ fhir:v "HIP" ] ; fhir:display [ fhir:v "health insurance plan policy" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "preventive-care" ] ] ) ] ; fhir:requirement [ fhir:v "No prior authorization required for in-network preventive services" ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "primary-care-visit" ] ] ) ] ; fhir:requirement [ fhir:v "No referral required" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation> ] ; fhir:value [ a fhir:String ; fhir:v "Limited to network specialists only; out-of-network not covered except in emergencies" ] ] ) ; fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "specialist-visit" ] ] ) ] ; fhir:requirement [ fhir:v "Referral required from primary care physician" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation> ] ; fhir:value [ a fhir:String ; fhir:v "Copay waived if admitted to hospital" ] ] ) ; fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "emergency-room-care" ] ] ) ] ] [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "hospital-inpatient" ] ] ) ] ; fhir:requirement [ fhir:v "Prior authorization required for non-emergency admissions" ] ] ) ] ) ; # fhir:plan ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type> ] ; fhir:code [ fhir:v "HMO" ] ] ) ] ; ( fhir:generalCost [ fhir:type [ fhir:text [ fhir:v "Individual Deductible" ] ] ; fhir:cost [ fhir:value [ fhir:v "1500"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ; fhir:comment [ fhir:v "Individual in-network deductible" ] ] [ fhir:type [ fhir:text [ fhir:v "Family Deductible" ] ] ; fhir:cost [ fhir:value [ fhir:v "3000"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:type [ fhir:text [ fhir:v "Individual Out-of-Pocket Maximum" ] ] ; fhir:cost [ fhir:value [ fhir:v "6000"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:type [ fhir:text [ fhir:v "Family Out-of-Pocket Maximum" ] ] ; fhir:cost [ fhir:value [ fhir:v "12000"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ; ( fhir:specificCost [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "preventive-care" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "preventive-care" ] ] ) ] ; ( fhir:cost [ fhir:type [ fhir:text [ fhir:v "No charge" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "in-network" ] ; fhir:display [ fhir:v "In Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] [ fhir:type [ fhir:text [ fhir:v "Not covered" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "out-of-network" ] ; fhir:display [ fhir:v "Out of Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "primary-care-visit" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "primary-care-visit" ] ] ) ] ; ( fhir:cost [ fhir:type [ fhir:text [ fhir:v "Copayment" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "in-network" ] ; fhir:display [ fhir:v "In Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "25"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] [ fhir:type [ fhir:text [ fhir:v "Not covered" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "out-of-network" ] ; fhir:display [ fhir:v "Out of Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "specialist-visit" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "specialist-visit" ] ] ) ] ; ( fhir:cost [ fhir:type [ fhir:text [ fhir:v "Copayment" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "in-network" ] ; fhir:display [ fhir:v "In Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "50"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] [ fhir:type [ fhir:text [ fhir:v "Not covered" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "out-of-network" ] ; fhir:display [ fhir:v "Out of Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "emergency-room-care" ] ] ) ] ; ( fhir:benefit [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation> ] ; fhir:value [ a fhir:String ; fhir:v "Copay waived if admitted" ] ] ) ; fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "emergency-room-care" ] ] ) ] ; ( fhir:cost [ fhir:type [ fhir:text [ fhir:v "Copayment" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "in-network" ] ; fhir:display [ fhir:v "In Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "350"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] [ fhir:type [ fhir:text [ fhir:v "Copayment" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "out-of-network" ] ; fhir:display [ fhir:v "Out of Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "350"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "generic-drugs" ] ] ) ] ; ( fhir:benefit [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "generic-drugs" ] ] ) ] ; ( fhir:cost [ fhir:type [ fhir:text [ fhir:v "Copayment" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "in-network" ] ; fhir:display [ fhir:v "In Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "10"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] [ fhir:type [ fhir:text [ fhir:v "Not covered" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "out-of-network" ] ; fhir:display [ fhir:v "Out of Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "USD" ] ] ] ) ] ) ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "hospital-inpatient" ] ] ) ] ; ( fhir:benefit [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation> ] ; fhir:value [ a fhir:String ; fhir:v "Prior authorization required" ] ] ) ; fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category> ] ; fhir:code [ fhir:v "hospital-inpatient" ] ] ) ] ; ( fhir:cost [ fhir:type [ fhir:text [ fhir:v "Coinsurance" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "in-network" ] ; fhir:display [ fhir:v "In Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "20"^^xsd:decimal ] ; fhir:unit [ fhir:v "%" ] ] ] [ fhir:type [ fhir:text [ fhir:v "Not covered" ] ] ; fhir:applicability [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/applicability"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/applicability> ] ; fhir:code [ fhir:v "out-of-network" ] ; fhir:display [ fhir:v "Out of Network" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:unit [ fhir:v "%" ] ] ] ) ] ) ] ) ] ) . #
IG © 2026+ HL7 International / Payer/Provider Information Exchange Work Group. Package hl7.fhir.us.insurance-card#2.0.0 based on FHIR 4.0.1. Generated 2026-02-03
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