Bidirectional Services eReferral (BSeR)
2.0.0-ballot - STU2 United States of America flag

This page is part of the Bidirectional Services eReferrals (BSeR) (v2.0.0-ballot: STU 2) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

: Coverage - Baby Everybaby - XML Representation

Raw xml | Download



<Coverage xmlns="http://hl7.org/fhir">
  <id value="coverage-bser-coverage-baby-everybaby"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-Coverage"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Coverage</b><a name="coverage-bser-coverage-baby-everybaby"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Coverage &quot;coverage-bser-coverage-baby-everybaby&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-BSeR-Coverage.html">BSeR Coverage</a></p></div><p><b>identifier</b>: Member Number: 12345</p><p><b>status</b>: active</p><p><b>type</b>: extended healthcare <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-v3-ActCode.html">ActCode</a>#EHCPOL)</span></p><p><b>subscriber</b>: <a href="RelatedPerson-relatedperson-us-core-relatedperson-mom-everymom.html">RelatedPerson/relatedperson-us-core-relatedperson-mom-everymom: Mom Everymom</a> &quot; EVERYMOM&quot;</p><p><b>beneficiary</b>: <a href="Patient-patient-us-core-patient-baby-everybaby.html">Patient/patient-us-core-patient-baby-everybaby: Baby Everybaby</a> &quot; EVERYBABY&quot;</p><p><b>relationship</b>: gestational mother <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-v3-RoleCode.html">RoleCode</a>#GESTM)</span></p><p><b>period</b>: 2019-05-23 --&gt; 2020-05-23</p><p><b>payor</b>: <a href="Organization-organization-us-core-organization-saint-luke.html">Organization/organization-us-core-organization-saint-luke</a> &quot;Saint Luke's Hospital of Kansas City&quot;</p><blockquote><p><b>class</b></p><p><b>type</b>: Group <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#group; <a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#subgroup)</span></p><p><b>value</b>: 123</p><p><b>name</b>: Trainee Part-time Benefits</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: Plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#plan; <a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#subplan)</span></p><p><b>value</b>: P7</p><p><b>name</b>: Includes afterlife benefits</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: Class <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#class)</span></p><p><b>value</b>: SILVER</p><p><b>name</b>: Silver: Family Plan spouse only</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: SubClass <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#subclass)</span></p><p><b>value</b>: Tier2</p><p><b>name</b>: Low deductable, max $20 copay</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: Sequence <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#sequence)</span></p><p><b>value</b>: 9</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: RX Id <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#rxid)</span></p><p><b>value</b>: MDF12345</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: RX BIN <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#rxbin)</span></p><p><b>value</b>: 987654</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: RX Group <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#rxgroup)</span></p><p><b>value</b>: M35PT</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: RX PCN <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#rxpcn)</span></p><p><b>value</b>: 234516</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: Sequence <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#sequence)</span></p><p><b>value</b>: 9</p></blockquote></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="MB"/>
        <display value="Member Number"/>
      </coding>
    </type>
    <system value="http://benefitsinc.com/certificate"/>
    <value value="12345"/>
  </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="RelatedPerson/relatedperson-us-core-relatedperson-mom-everymom"/>
    <display value="Mom Everymom"/>
  </subscriber>
  <beneficiary>
    <reference value="Patient/patient-us-core-patient-baby-everybaby"/>
    <display value="Baby Everybaby"/>
  </beneficiary>
  <relationship>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode"/>
      <code value="GESTM"/>
      <display value="gestational mother"/>
    </coding>
    <text value="gestational mother"/>
  </relationship>
  <period>
    <start value="2019-05-23"/>
    <end value="2020-05-23"/>
  </period>
  <payor>
    <reference
               value="Organization/organization-us-core-organization-saint-luke"/>
  </payor>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="group"/>
      </coding>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="subgroup"/>
      </coding>
    </type>
    <value value="123"/>
    <name value="Trainee Part-time Benefits"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="plan"/>
      </coding>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="subplan"/>
      </coding>
    </type>
    <value value="P7"/>
    <name value="Includes afterlife benefits"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="class"/>
      </coding>
    </type>
    <value value="SILVER"/>
    <name value="Silver: Family Plan spouse only"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="subclass"/>
      </coding>
    </type>
    <value value="Tier2"/>
    <name value="Low deductable, max $20 copay"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="sequence"/>
      </coding>
    </type>
    <value value="9"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="rxid"/>
      </coding>
    </type>
    <value value="MDF12345"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="rxbin"/>
      </coding>
    </type>
    <value value="987654"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="rxgroup"/>
      </coding>
    </type>
    <value value="M35PT"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="rxpcn"/>
      </coding>
    </type>
    <value value="234516"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="sequence"/>
      </coding>
    </type>
    <value value="9"/>
  </class>
</Coverage>