Coverage-example-2.xml

General Person Secondary Coverage Example (id = "7546D")

<?xml version="1.0" encoding="UTF-8"?>

<Coverage xmlns="http://hl7.org/fhir">
  <id value="7546D"/> 

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

  <identifier> 
    <system value="http://xyz.com/codes/identifier"/> 
    <value value="AB98761"/> 
  </identifier> 

  <status value="active"/> 

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

  <subscriber> 
    <reference value="Patient/5"/> 
  </subscriber> 

  <subscriberId> 
    <value value="AB9876"/> 
  </subscriberId> 

  <beneficiary> 
    <reference value="Patient/5"/> 
  </beneficiary> 

  <dependent value="1"/> 

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

  <period>  
    <start value="2011-03-17"/> 
    <end value="2012-03-17"/> 
  </period> 

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

  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="group"/> 
      </coding> 
    </type> 
    <value value="WESTAIR"/> 
    <name value="Western Airlines"/> 
  </class> 

  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="plan"/> 
      </coding> 
    </type> 
    <value value="BG4352"/> 
    <name value="Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"/> 
  </class> 

  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="subplan"/> 
      </coding> 
    </type> 
    <value value="D15C9"/> 
    <name value="Platinum"/> 
  </class> 

  <order value="2"/>  <!--   Second after the national medical coverage   -->

  <network value="5"/> 

  <costToBeneficiary> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/> 
        <code value="gpvisit"/>  <!--   normally $40.00   -->
      </coding> 
    </type> 
    <valueMoney> 
      <value value="20.00"/> 
      <currency value="USD"/> 
    </valueMoney> 
    <exception> 
      <type> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-coverage-financial-exception"/> 
          <code value="retired"/> 
        </coding> 
      </type> 
      <period> 
        <start value="2018-01-01"/> 
        <end value="2018-12-31"/> 
      </period> 
    </exception> 
  </costToBeneficiary> 

  <contract> 
    <reference value="Contract/INS-101"/> 
  </contract> 

</Coverage>