Eligibilityresponse-example-benefits.xml

General Person Primary Coverage with Benefit Details (id = "E2500")

<EligibilityResponse xmlns="http://hl7.org/fhir">
 <id value="E2500"/>

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

  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/eligibilityresponse"/>
    <value value="881234"/>
  </identifier>
  
  <status value="active"/>

  <requestReference>
  <reference value="http://www.BenefitsInc.com/fhir/eligibility/225476332402"/>
  </requestReference>
  
  <outcome value="complete"/>
  
  <disposition value="Policy is currently in-force."/>
 
  <created value="2014-08-16"/>

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

  <inforce value="true"/>
  
  <benefitBalance>
    <category>
    <system value="http://hl7.org/fhir/benefit-category"/>
    <code value="medical"/>
  </category>
  
  <subCategory>
    <system value="http://hl7.org/fhir/benefit-subcategory"/>
    <code value="30"/>
    <display value="Health Benefit Plan Coverage"/>
  </subCategory>

  <network>
    <system value="http://hl7.org/fhir/benefit-network"/>
    <code value="in"/>
  </network>
  
  <unit>
    <system value="http://hl7.org/fhir/benefit-unit"/>
    <code value="individual"/>
  </unit>
  
  <term>
    <system value="http://hl7.org/fhir/benefit-term"/>
    <code value="annual"/>
  </term>
  
  <financial>
    <type>
      <code value="benefit"/>
    </type>
    
    <benefitMoney>
      <value value="500000"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="SAR"/> 
    </benefitMoney>
  </financial>
  
  <financial>
    <type>
      <code value="copay-maximum"/>
    </type>
    
    <benefitMoney>
      <value value="100"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="SAR"/> 
    </benefitMoney>
  </financial>

  <financial>
    <type>
      <code value="copay-percent"/>
    </type>
    
    <benefitUnsignedInt value="20"/>
  </financial>
  </benefitBalance>

  <benefitBalance>
    <category>
    <system value="http://hl7.org/fhir/benefit-category"/>
    <code value="medical"/>
  </category>
  
  <subCategory>
    <system value="http://hl7.org/fhir/benefit-subcategory"/>
    <code value="69"/>
    <display value="Maternity"/>
  </subCategory>

  <network>
    <system value="http://hl7.org/fhir/benefit-network"/>
    <code value="in"/>
  </network>
  
  <unit>
    <system value="http://hl7.org/fhir/benefit-unit"/>
    <code value="individual"/>
  </unit>
  
  <term>
    <system value="http://hl7.org/fhir/benefit-term"/>
    <code value="annual"/>
  </term>
  
  <financial>
    <type>
      <code value="benefit"/>
    </type>
    
    <benefitMoney>
      <value value="15000"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="SAR"/> 
    </benefitMoney>
  </financial>
  
  </benefitBalance>
  <benefitBalance>
    <category>
    <system value="http://hl7.org/fhir/benefit-category"/>
    <code value="oral"/>
  </category>
  
  <subCategory>
    <system value="http://hl7.org/fhir/benefit-subcategory"/>
    <code value="F3"/>
    <display value="Dental Coverage"/>
  </subCategory>

  <network>
    <system value="http://hl7.org/fhir/benefit-network"/>
    <code value="in"/>
  </network>
  
  <unit>
    <system value="http://hl7.org/fhir/benefit-unit"/>
    <code value="individual"/>
  </unit>
  
  <term>
    <system value="http://hl7.org/fhir/benefit-term"/>
    <code value="annual"/>
  </term>
  
  <financial>
    <type>
      <code value="benefit"/>
    </type>
    
    <benefitMoney>
      <value value="2000"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="SAR"/> 
    </benefitMoney>
  </financial>
  
  </benefitBalance>
  <benefitBalance>
    <category>
    <system value="http://hl7.org/fhir/benefit-category"/>
    <code value="vision"/>
  </category>
  
  <subCategory>
    <system value="http://hl7.org/fhir/benefit-subcategory"/>
    <code value="F6"/>
    <display value="Vision Coverage"/>
  </subCategory>

  <network>
    <system value="http://hl7.org/fhir/benefit-network"/>
    <code value="in"/>
  </network>
  
  <unit>
    <system value="http://hl7.org/fhir/benefit-unit"/>
    <code value="individual"/>
  </unit>
  
  <term>
    <system value="http://hl7.org/fhir/benefit-term"/>
    <code value="annual"/>
  </term>
  
  <financial>
    <type>
      <code value="benefit"/>
    </type>
    
    <benefitMoney>
      <value value="400"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="SAR"/> 
    </benefitMoney>
  </financial>
  
  </benefitBalance>
  <benefitBalance>
    <category>
    <system value="http://hl7.org/fhir/benefit-category"/>
    <code value="vision"/>
  </category>
  
  <subCategory>
    <system value="http://hl7.org/fhir/benefit-subcategory"/>
    <code value="49"/>
    <display value="Hospital Room and Board"/>
  </subCategory>

  <network>
    <system value="http://hl7.org/fhir/benefit-network"/>
    <code value="in"/>
  </network>
  
  <unit>
    <system value="http://hl7.org/fhir/benefit-unit"/>
    <code value="individual"/>
  </unit>
  
  <term>
    <system value="http://hl7.org/fhir/benefit-term"/>
    <code value="day"/>
  </term>
  
  <financial>
    <type>
      <code value="room"/>
    </type>
    
    <benefitString value="shared"/>
  </financial>
  <financial>
    <type>
      <code value="benefit"/>
    </type>
    
    <benefitMoney>
      <value value="600"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="SAR"/> 
    </benefitMoney>
  </financial>
  
  </benefitBalance>
  
</EligibilityResponse>