STU 3 Ballot

This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Eligibilityresponse-example-benefits.json

Raw JSON (canonical form)

General Person Primary Coverage with Benefit Details

{
  "resourceType": "EligibilityResponse",
  "id": "E2500",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the EligibilityResponse.</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/eligibilityresponse",
      "value": "881234"
    }
  ],
  "status": "active",
  "requestReference": {
    "reference": "http://www.BenefitsInc.com/fhir/eligibility/225476332402"
  },
  "outcome": "complete",
  "disposition": "Policy is currently in-force.",
  "created": "2014-08-16",
  "organizationReference": {
    "reference": "Organization/2"
  },
  "inforce": true,
  "benefitBalance": [
    {
      "category": {
        "system": "http://hl7.org/fhir/benefit-category",
        "code": "medical"
      },
      "subCategory": {
        "system": "http://hl7.org/fhir/benefit-subcategory",
        "code": "30",
        "display": "Health Benefit Plan Coverage"
      },
      "network": {
        "system": "http://hl7.org/fhir/benefit-network",
        "code": "in"
      },
      "unit": {
        "system": "http://hl7.org/fhir/benefit-unit",
        "code": "individual"
      },
      "term": {
        "system": "http://hl7.org/fhir/benefit-term",
        "code": "annual"
      },
      "financial": [
        {
          "type": {
            "code": "benefit"
          },
          "benefitMoney": {
            "value": 500000,
            "system": "urn:iso:std:iso:4217",
            "code": "SAR"
          }
        },
        {
          "type": {
            "code": "copay-maximum"
          },
          "benefitMoney": {
            "value": 100,
            "system": "urn:iso:std:iso:4217",
            "code": "SAR"
          }
        },
        {
          "type": {
            "code": "copay-percent"
          },
          "benefitUnsignedInt": 20
        }
      ]
    },
    {
      "category": {
        "system": "http://hl7.org/fhir/benefit-category",
        "code": "medical"
      },
      "subCategory": {
        "system": "http://hl7.org/fhir/benefit-subcategory",
        "code": "69",
        "display": "Maternity"
      },
      "network": {
        "system": "http://hl7.org/fhir/benefit-network",
        "code": "in"
      },
      "unit": {
        "system": "http://hl7.org/fhir/benefit-unit",
        "code": "individual"
      },
      "term": {
        "system": "http://hl7.org/fhir/benefit-term",
        "code": "annual"
      },
      "financial": [
        {
          "type": {
            "code": "benefit"
          },
          "benefitMoney": {
            "value": 15000,
            "system": "urn:iso:std:iso:4217",
            "code": "SAR"
          }
        }
      ]
    },
    {
      "category": {
        "system": "http://hl7.org/fhir/benefit-category",
        "code": "oral"
      },
      "subCategory": {
        "system": "http://hl7.org/fhir/benefit-subcategory",
        "code": "F3",
        "display": "Dental Coverage"
      },
      "network": {
        "system": "http://hl7.org/fhir/benefit-network",
        "code": "in"
      },
      "unit": {
        "system": "http://hl7.org/fhir/benefit-unit",
        "code": "individual"
      },
      "term": {
        "system": "http://hl7.org/fhir/benefit-term",
        "code": "annual"
      },
      "financial": [
        {
          "type": {
            "code": "benefit"
          },
          "benefitMoney": {
            "value": 2000,
            "system": "urn:iso:std:iso:4217",
            "code": "SAR"
          }
        }
      ]
    },
    {
      "category": {
        "system": "http://hl7.org/fhir/benefit-category",
        "code": "vision"
      },
      "subCategory": {
        "system": "http://hl7.org/fhir/benefit-subcategory",
        "code": "F6",
        "display": "Vision Coverage"
      },
      "network": {
        "system": "http://hl7.org/fhir/benefit-network",
        "code": "in"
      },
      "unit": {
        "system": "http://hl7.org/fhir/benefit-unit",
        "code": "individual"
      },
      "term": {
        "system": "http://hl7.org/fhir/benefit-term",
        "code": "annual"
      },
      "financial": [
        {
          "type": {
            "code": "benefit"
          },
          "benefitMoney": {
            "value": 400,
            "system": "urn:iso:std:iso:4217",
            "code": "SAR"
          }
        }
      ]
    },
    {
      "category": {
        "system": "http://hl7.org/fhir/benefit-category",
        "code": "vision"
      },
      "subCategory": {
        "system": "http://hl7.org/fhir/benefit-subcategory",
        "code": "49",
        "display": "Hospital Room and Board"
      },
      "network": {
        "system": "http://hl7.org/fhir/benefit-network",
        "code": "in"
      },
      "unit": {
        "system": "http://hl7.org/fhir/benefit-unit",
        "code": "individual"
      },
      "term": {
        "system": "http://hl7.org/fhir/benefit-term",
        "code": "day"
      },
      "financial": [
        {
          "type": {
            "code": "room"
          },
          "benefitString": "shared"
        },
        {
          "type": {
            "code": "benefit"
          },
          "benefitMoney": {
            "value": 600,
            "system": "urn:iso:std:iso:4217",
            "code": "SAR"
          }
        }
      ]
    }
  ]
}

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.