---
type: "example"
title: "Contract Example: contract-example-ins-policy"
resource: "Contract"
example: "contract-example-ins-policy"
---
# Contract Example: contract-example-ins-policy

## Narrative

Plan: Your Choice Split Copay (Non-Grandfathered)

Certificate Form Number: YCSCWLN (01-2017)

## Example XML



```xml
<?xml version="1.0" encoding="UTF-8"?>
<Contract xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
   xsi:schemaLocation="http://hl7.org/fhir ../../schema/contract.xsd">
   <id value="INS-101"/>

   <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
         <p>Plan: Your Choice Split Copay (Non-Grandfathered)</p>
         <p>Certificate Form Number: YCSCWLN (01-2017)</p>
      </div>
   </text>

   <identifier>
      <system value="http://xyz-insurance.com/forms"/>
      <value value="YCSCWLN(01-2017)"/>
   </identifier>
   
   <applies>
      <start value="2017-01-01"/>
   </applies>
   
   <subject>
      <reference value="Patient/1"/>
   </subject>
   
   <type>
      <coding>
         <system value="http://terminology.hl7.org/CodeSystem/contract-type"/>
         <code value="healthinsurance"/>
         <display value="Health Insurance"/>
      </coding>
   </type>
   
   <term>
      <offer>
         <text value="The benefits, limitations, exclusions and other coverage provisions in this booklet are subject to the terms of our contract with the Group. This booklet is a part of that contract, which is on file in the Group's office."/>
      </offer>
      <asset>
         <type>
            <coding>
            <system value="urn:ietf:rfc:3986"/>
            <code value="urn:uuid:3a48c68c-318d-4c68-8471-4a3c10fcb41b"/>
            <display value="RicardianContract"/>
         </coding>
         </type>
         <subtype>
            <text value="sample"/>
         </subtype>
         <period>
            <start value="2017-06-01"/>
         </period>
         <valuedItem>
            <entityCodeableConcept>
               <text value="Ford Bobcat"/>
            </entityCodeableConcept>
            <identifier>
               <system value="http://somewhere.motor-vehicle.com/vin"/>
               <value value="XXSVT34-7665t952236"/>
            </identifier>
            <effectiveTime value="1995"/>
            <quantity>
               <value value="1"/>
            </quantity>
            <unitPrice>
               <value value="200.00"/>
               <currency value="CAD"/>
            </unitPrice>
            <factor value="1.0"/>
            <points value="1.0"/>
            <net>
               <value value="200.00"/>
               <currency value="CAD"/>
            </net>
         </valuedItem>
      </asset>
      <group>
         <offer>
            <text value="Eligible Providers"/>
         </offer>
      </group>
      <group>
         <offer>
            <text value="Responsibility for Payment"/>
         </offer>
      </group>
      <group>
         <offer>
            <text value="List of Benefits"/>
         </offer>
         <group>
            <offer>
               <text value="Copays"/>
            </offer>
            <group>
               <offer>
                  <text value="Emergency Room Copay"/>
               </offer>
            </group>
            <group>
               <offer>
                  <text value="Professional Visit Copay"/>
               </offer>
            </group>
         </group>
         <group>
            <offer>
               <text value="Calendar Year Deductible"/>
            </offer>
         </group>
         <group>
            <offer>
               <text value="Out-Of-Pocket Maximum"/>
            </offer>
         </group>
         <group>
            <offer>
               <text value="Medical Services"/>
            </offer>
            <group>
               <offer>
                  <text value="Ambulance Services"/>
               </offer>
            </group>
            <group>
               <offer>
                  <text value="Dental Services"/>
               </offer>
            </group>
            <group>
               <offer>
                  <text value="Diagnostic Services"/>
               </offer>
            </group>
            <group>
               <offer>
                  <text value="Emergency Room Services"/>
               </offer>
            </group>
            <group>
               <offer>
                  <text value="Hospital Inpatient Care"/>
               </offer>
            </group>
         </group>
      </group>
   </term>
</Contract>
```