FHIR Release 3 (STU)

This page is part of the FHIR Specification (v3.0.2: STU 3). 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

Financial Management Work GroupMaturity Level: N/ABallot Status: InformativeCompartments: Practitioner

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

<EligibilityResponse 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 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> 

        <allowedMoney> 
          <value value="500000"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="SAR"/>  
        </allowedMoney> 
      </financial> 

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

        <allowedMoney> 
          <value value="100"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="SAR"/>  
        </allowedMoney> 
      </financial> 

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

        <allowedUnsignedInt 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> 

        <allowedMoney> 
          <value value="15000"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="SAR"/>  
        </allowedMoney> 
      </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> 

        <allowedMoney> 
          <value value="2000"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="SAR"/>  
        </allowedMoney> 
      </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> 

        <allowedMoney> 
          <value value="400"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="SAR"/>  
        </allowedMoney> 
      </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> 

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

        <allowedMoney> 
          <value value="600"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="SAR"/>  
        </allowedMoney> 
      </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.