Release 4B Snapshot #1

This page is part of the FHIR Specification (v4.3.0-snapshot1: Release 4B Snapshot #1). 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

Coverageeligibilityresponse-example-benefits.xml

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Patient, Practitioner

Raw XML (canonical form + also see XML Format Specification)

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General Person Primary Coverage with Benefit Details (id = "E2501")

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

<CoverageEligibilityResponse xmlns="http://hl7.org/fhir">
  <id value="E2501"/> 

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

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

  <status value="active"/> 

  <purpose value="validation"/> 
  <purpose value="benefits"/> 

  <patient> 
    <reference value="Patient/pat1"/> 
  </patient> 

  <servicedDate value="2014-09-17"/>  <!--   Anticipated service date   -->

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

  <request> 
    <reference value="http://www.BenefitsInc.com/fhir/coverageeligibilityresponse/225476332402"/> 
  </request> 

  <outcome value="complete"/> 

  <disposition value="Policy is currently in-force."/> 

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

  <insurance> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
    <inforce value="true"/> 

    <item> 
      <category> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/> 
          <code value="30"/> 
          <display value="Health Benefit Plan Coverage"/> 
        </coding> 
      </category> 

      <network> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/> 
          <code value="in"/> 
        </coding> 
      </network> 

      <unit> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/> 
          <code value="individual"/> 
        </coding> 
      </unit> 

      <term> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/> 
          <code value="annual"/> 
        </coding> 
      </term> 

      <benefit> 
        <type> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </type> 

        <allowedMoney> 
          <value value="500000"/> 
          <currency value="SAR"/>  
        </allowedMoney> 
      </benefit> 

      <benefit> 
        <type> 
          <coding> 
            <code value="copay-maximum"/> 
          </coding> 
        </type> 

        <allowedMoney> 
          <value value="100"/> 
          <currency value="SAR"/>  
        </allowedMoney> 
      </benefit> 

      <benefit> 
        <type> 
          <coding> 
            <code value="copay-percent"/> 
          </coding> 
        </type> 

        <allowedUnsignedInt value="20"/> 
      </benefit> 
    </item> 

    <item> 
      <category> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/> 
          <code value="69"/> 
          <display value="Maternity"/> 
        </coding> 
      </category> 

      <network> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/> 
          <code value="in"/> 
        </coding> 
      </network> 

      <unit> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/> 
          <code value="individual"/> 
        </coding> 
      </unit> 

      <term> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/> 
          <code value="annual"/> 
        </coding> 
      </term> 

      <benefit> 
        <type> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </type> 

        <allowedMoney> 
          <value value="15000"/> 
          <currency value="SAR"/>  
        </allowedMoney> 
      </benefit> 

    </item> 
    <item> 
      <category> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/> 
          <code value="F3"/> 
          <display value="Dental Coverage"/> 
        </coding> 
      </category> 

      <network> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/> 
          <code value="in"/> 
        </coding> 
      </network> 

      <unit> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/> 
          <code value="individual"/> 
        </coding> 
      </unit> 

      <term> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/> 
          <code value="annual"/> 
        </coding> 
      </term> 

      <benefit> 
        <type> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </type> 

        <allowedMoney> 
          <value value="2000"/> 
          <currency value="SAR"/>  
        </allowedMoney> 
      </benefit> 

    </item> 
    <item> 
      <category> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/> 
          <code value="F6"/> 
          <display value="Vision Coverage"/> 
        </coding> 
      </category> 

      <network> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/> 
          <code value="in"/> 
        </coding> 
      </network> 

      <unit> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/> 
          <code value="individual"/> 
        </coding> 
      </unit> 

      <term> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/> 
          <code value="annual"/> 
        </coding> 
      </term> 

      <benefit> 
        <type> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </type> 

        <allowedMoney> 
          <value value="400"/> 
          <currency value="SAR"/>  
        </allowedMoney> 
      </benefit> 

    </item> 
    <item> 
      <category> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/> 
          <code value="49"/> 
          <display value="Hospital Room and Board"/> 
        </coding> 
      </category> 

      <network> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/> 
          <code value="in"/> 
        </coding> 
      </network> 

      <unit> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/> 
          <code value="individual"/> 
        </coding> 
      </unit> 

      <term> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/> 
          <code value="day"/> 
        </coding> 
      </term> 

      <benefit> 
        <type> 
          <coding> 
            <code value="room"/> 
          </coding> 
        </type> 

        <allowedString value="shared"/> 
      </benefit> 
      <benefit> 
        <type> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </type> 

        <allowedMoney> 
          <value value="600"/> 
          <currency value="SAR"/>  
        </allowedMoney> 
      </benefit> 

    </item> 
  </insurance> 

</CoverageEligibilityResponse>

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.