This page is part of the FHIR Specification (v5.0.0-ballot: R5 Ballot - see ballot notes). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4
Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Patient, Practitioner |
Raw JSON (canonical form + also see JSON Format Specification)
General Person Primary Coverage with Benefit Details and new insurance
{ "resourceType": "CoverageEligibilityResponse", "id": "E2502", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the CoverageEligibilityResponse.</div>" }, "contained": [ { "resourceType": "Coverage", "id": "coverage-1", "identifier": [ { "system": "http://benefitsinc.com/certificate", "value": "12345" } ], "status": "active", "kind": "insurance", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "EHCPOL" } ] }, "subscriber": { "reference": "Patient/f201" }, "beneficiary": { "reference": "Patient/f201" }, "dependent": "1", "relationship": { "coding": [ { "code": "self" } ] }, "insurer": { "identifier": { "system": "http://www.bindb.com/bin", "value": "123456" } }, "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "EHCPOL" } ] }, "value": { "value": "CBI35" }, "name": "Corporate Baker's Inc. Plan#35" }, { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "subplan" } ] }, "value": { "value": "123" }, "name": "Trainee Part-time Benefits" }, { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "sequence" } ] }, "value": { "value": "1" } } ] } ], "identifier": [ { "system": "http://www.BenefitsInc.com/fhir/coverageeligibilityresponse", "value": "8812342" } ], "status": "active", "purpose": [ "validation", "benefits" ], "patient": { "reference": "Patient/f201" }, "created": "2014-09-16", "requestor": { "identifier": { "system": "http://national.org/clinic", "value": "OR1234" } }, "request": { "reference": "http://www.BenefitsInc.com/fhir/coverageeligibilityrequest/225476332405" }, "outcome": "complete", "disposition": "Policy is currently in-force.", "insurer": { "reference": "Organization/2" }, "insurance": [ { "coverage": { "reference": "#coverage-1" }, "inforce": true, "item": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory", "code": "30", "display": "Health Benefit Plan Coverage" } ] }, "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in" } ] }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual" } ] }, "term": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-term", "code": "annual" } ] }, "benefit": [ { "type": { "coding": [ { "code": "benefit" } ] }, "allowedMoney": { "value": 500000, "currency": "USD" }, "usedMoney": { "value": 3748.00, "currency": "USD" } }, { "type": { "coding": [ { "code": "copay-maximum" } ] }, "allowedMoney": { "value": 100, "currency": "USD" } }, { "type": { "coding": [ { "code": "copay-percent" } ] }, "allowedUnsignedInt": 20 } ] }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory", "code": "69", "display": "Maternity" } ] }, "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in" } ] }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual" } ] }, "term": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-term", "code": "annual" } ] }, "benefit": [ { "type": { "coding": [ { "code": "benefit" } ] }, "allowedMoney": { "value": 15000, "currency": "USD" } } ] }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory", "code": "F3", "display": "Dental Coverage" } ] }, "network": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-network", "code": "in" } ] }, "unit": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-unit", "code": "individual" } ] }, "term": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/benefit-term", "code": "annual" } ] }, "benefit": [ { "type": { "coding": [ { "code": "benefit" } ] }, "allowedMoney": { "value": 2000, "currency": "USD" } } ] }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory", "code": "F6", "display": "Vision Coverage" } ] }, "excluded": true, "name": "Vision", "description": "Vision products and services such as exams, glasses and contact lenses." } ] } ], "form": { "coding": [ { "system": "http://national.org/form", "code": "ELRSP/2017/01" } ] } }
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.
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