STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). 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.xml

Raw XML (canonical form)

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"/>

  <created value="2014-08-16"/>

  <request>
  <reference value="http://www.BenefitsInc.com/fhir/eligibility/225476332402"/>
  </request>
  
  <outcome>
   <coding>
    <system value="http://hl7.org/fhir/remittance-outcome"/>
  <code value="complete"/>
   </coding>
  </outcome>
  
  <disposition value="Policy is currently in-force."/>
 
  <insurer>
    <reference value="Organization/2"/>
  </insurer>

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

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

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

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

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

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

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

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

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.