# Submit Claim Insurance Example - Da Vinci Prior Authorization Support (PAS) FHIR IG v2.2.0-ballot

## Example Coverage: Submit Claim Insurance Example

Language: en

Profile: [PAS Coverage](StructureDefinition-profile-coverage.md)

**status**: Active

**subscriberId**: 1122334455

**beneficiary**: [JOE SMITH Male, DoB Unknown ( Member Number)](Patient-SubscriberExample.md)

**relationship**: Self

**payor**: [Organization MARYLAND CAPITAL INSURANCE COMPANY](Organization-InsurerExample.md)



## Resource Content

```json
{
  "resourceType" : "Coverage",
  "id" : "InsuranceExample",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"
    ]
  },
  "language" : "en",
  "status" : "active",
  "subscriberId" : "1122334455",
  "beneficiary" : {
    "reference" : "Patient/SubscriberExample"
  },
  "relationship" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
        "code" : "self"
      },
      {
        "system" : "https://codesystem.x12.org/005010/1069",
        "code" : "18"
      }
    ]
  },
  "payor" : [
    {
      "reference" : "Organization/InsurerExample"
    }
  ]
}

```
