CoverageEligibilityResponse Example: coverageeligibilityresponse-example-benefits-2

Narrative

A human-readable rendering of the CoverageEligibilityResponse.

Example XML

<CoverageEligibilityResponse xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/remittance.xsd">
    <id value="E2502"/>

    <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the CoverageEligibilityResponse.</div>
    </text>

    <contained>
        <Coverage>
            <id value="coverage-1"/>

            <identifier>
                <system value="http://benefitsinc.com/certificate"/>
                <value value="12345"/>
            </identifier>

            <status value="active"/>

            <kind value="insurance"/>

            <type>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
                    <code value="EHCPOL"/>
                </coding>
            </type>

            <subscriber>
                <reference value="Patient/f201"/>
            </subscriber>

            <beneficiary>
                <reference value="Patient/f201"/>
            </beneficiary>
            <dependent value="1"/>

            <relationship>
                <coding>
                    <code value="self"/>
                </coding>
            </relationship>

            <insurer>
                <identifier>
                    <system value="http://www.bindb.com/bin"/>
                    <value value="123456"/>
                </identifier>
            </insurer>

            <class>
                <type>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
                        <code value="EHCPOL"/>
                    </coding>
                </type>
                <value>
                    <value value="CBI35"/>
                </value>
                <name value="Corporate Baker's Inc. Plan#35"/>
            </class>

            <class>
                <type>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                        <code value="subplan"/>
                    </coding>
                </type>
                <value>
                    <value value="123"/>
                </value>
                <name value="Trainee Part-time Benefits"/>
            </class>

            <class>
                <type>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                        <code value="sequence"/>
                    </coding>
                </type>
                <value>
                    <value value="1"/>
                </value>
            </class>

        </Coverage>
    </contained>

    <identifier>
        <system value="http://www.BenefitsInc.com/fhir/coverageeligibilityresponse"/>
        <value value="8812342"/>
    </identifier>

    <status value="active"/>

    <purpose value="validation"/>
    <purpose value="benefits"/>

    <patient>
        <reference value="Patient/f201"/>
    </patient>

    <created value="2014-09-16"/>

    <requestor>
        <identifier>
            <system value="http://national.org/clinic"/>
            <value value="OR1234"/>
        </identifier>   
    </requestor>

    <request>
        <reference value="http://www.BenefitsInc.com/fhir/coverageeligibilityrequest/225476332405"/>
    </request>

    <outcome value="complete" />

    <disposition value="Policy is currently in-force."/>

    <insurer>
        <reference value="Organization/2"/>
    </insurer>

    <insurance>
        <coverage>
            <reference value="#coverage-1"/>
        </coverage>

        <inforce value="true"/>

        <item>
            <category>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
                    <code value="30"/>
                    <display value="Health Benefit Plan Coverage"/>
                </coding>
            </category>

            <network>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
                    <code value="in"/>
                </coding>
            </network>

            <unit>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
                    <code value="individual"/>
                </coding>
            </unit>

            <term>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
                    <code value="annual"/>
                </coding>
            </term>

            <benefit>
                <type>
                    <coding>
                        <code value="benefit"/>
                    </coding>
                </type>

                <allowedMoney>
                    <value value="500000"/>
                    <currency value="USD"/> 
                </allowedMoney>

                <usedMoney>
                    <value value="3748.00"/>
                    <currency value="USD"/> 
                </usedMoney>

            </benefit>

            <benefit>
                <type>
                    <coding>
                        <code value="copay-maximum"/>
                    </coding>
                </type>

                <allowedMoney>
                    <value value="100"/>
                    <currency value="USD"/> 
                </allowedMoney>
            </benefit>

            <benefit>
                <type>
                    <coding>
                        <code value="copay-percent"/>
                    </coding>
                </type>

                <allowedUnsignedInt value="20"/>
            </benefit>
        </item>

        <item>
            <category>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
                    <code value="69"/>
                    <display value="Maternity"/>
                </coding>
            </category>

            <network>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
                    <code value="in"/>
                </coding>
            </network>

            <unit>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
                    <code value="individual"/>
                </coding>
            </unit>

            <term>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
                    <code value="annual"/>
                </coding>
            </term>

            <benefit>
                <type>
                    <coding>
                        <code value="benefit"/>
                    </coding>
                </type>

                <allowedMoney>
                    <value value="15000"/>
                    <currency value="USD"/> 
                </allowedMoney>
            </benefit>

        </item>
        <item>
            <category>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
                    <code value="F3"/>
                    <display value="Dental Coverage"/>
                </coding>
            </category>

            <network>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
                    <code value="in"/>
                </coding>
            </network>

            <unit>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
                    <code value="individual"/>
                </coding>
            </unit>

            <term>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
                    <code value="annual"/>
                </coding>
            </term>

            <benefit>
                <type>
                    <coding>
                        <code value="benefit"/>
                    </coding>
                </type>

                <allowedMoney>
                    <value value="2000"/>
                    <currency value="USD"/> 
                </allowedMoney>
            </benefit>

        </item>
        <item>
            <category>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
                    <code value="F6"/>
                    <display value="Vision Coverage"/>
                </coding>
            </category>

            <excluded value="true"/> <!-- this benefit category is not covered under the plan -->
            <name value="Vision"/>
            <description value="Vision products and services such as exams, glasses and contact lenses."/>

        </item>
    </insurance>

    <form>
        <coding>
            <system value="http://national.org/form"/>
            <code value="ELRSP/2017/01"/>
        </coding>
    </form>

</CoverageEligibilityResponse>