This page is part of the Bidirectional Services eReferrals (BSeR) (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

coverage-BSeR-Coverage-eve-everywoman - XML Representation

(back to description)

Raw xml

Source view

<Coverage xmlns="http://hl7.org/fhir">
  <id value="coverage-BSeR-Coverage-eve-everywoman"/>
  <meta>
    <versionId value="3"/>
    <lastUpdated value="2020-01-18T00:10:51.000-05:00"/>
    <profile
             value="http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-Coverage"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
            <table xmlns:xsl="http://www.w3.org/1999/XSL/Transform">
                <tr>
                    <td style="font-weight: bold">id</td>
                    <td>
                        <div title="id">coverage-BSeR-Coverage-eve-everywoman</div>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">meta</td>
                    <td>
                        <table>
                            <tr>
                                <td style="font-weight: bold">profile</td>
                                <td>
                                    <div title="profile">http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-Coverage</div>
                                </td>
                            </tr>
                        </table>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">identifier</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <div title="system">
                                    <a href="http://benefitsinc.com/certificate">http://benefitsinc.com/certificate</a>
                                </div>
                            </li>
                            <li>
                                <div title="value">12345</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">status</td>
                    <td>
                        <div title="status">active</div>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">type</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li>
                                        <div title="display">extended healthcare</div>  (
                                        
                                        
                                        <div title="code">EHCPOL</div> )
          
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/v3-ActCode">http://terminology.hl7.org/CodeSystem/v3-ActCode</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">subscriber</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li/>
                            <li>
                                <a href="RelatedPerson-relatedperson-self-eve-everywoman.html">Eve Everywoman</a>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">beneficiary</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li/>
                            <li>
                                <a href="Patient-patient-us-core-patient-eve-everywoman.html">Eve Everywoman</a>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">relationship</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">self</div> )
            
                                    
                                    
                                    </li>
                                </ul>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">period</td>
                    <td>
                        <table>
                            <tr>
                                <td style="font-weight: bold">start</td>
                                <td>
                                    <div title="start">2019-05-23</div>
                                </td>
                            </tr>
                            <tr>
                                <td style="font-weight: bold">end</td>
                                <td>
                                    <div title="end">2020-05-23</div>
                                </td>
                            </tr>
                        </table>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">payor</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <a href="Organization-organization-bser-organization-saint-luke.html">Organization/organization-bser-organization-saint-luke</a>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">group</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">CB135</div>
                            </li>
                            <li>
                                <div title="name">Corporate Baker's Inc. Local #35</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">subgroup</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">123</div>
                            </li>
                            <li>
                                <div title="name">Trainee Part-time Benefits</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">plan</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">B37FC</div>
                            </li>
                            <li>
                                <div title="name">Full Coverage: Medical, Dental, Pharmacy, Vision, EHC</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">subplan</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">P7</div>
                            </li>
                            <li>
                                <div title="name">Includes afterlife benefits</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">class</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">SILVER</div>
                            </li>
                            <li>
                                <div title="name">Silver: Family Plan spouse only</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">subclass</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">Tier2</div>
                            </li>
                            <li>
                                <div title="name">Low deductable, max $20 copay</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">sequence</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">9</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">rxid</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">MDF12345</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">rxbin</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">987654</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">rxgroup</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">M35PT</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">rxpcn</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">234516</div>
                            </li>
                        </ul>
                    </td>
                </tr>
                <tr>
                    <td style="font-weight: bold">class</td>
                    <td>
                        <ul style="list-style:none; padding-left:0; margin:0 0;">
                            <li>
                                <ul style="list-style:none; padding-left:0; margin:0 0;">
                                    <li> (
                                        
                                        
                                        <div title="code">sequence</div> )
            
                                    
                                    
                                    </li>
                                    <li>
                                        <div title="system">
                                            <a href="http://terminology.hl7.org/CodeSystem/coverage-class">http://terminology.hl7.org/CodeSystem/coverage-class</a>
                                        </div>
                                    </li>
                                </ul>
                            </li>
                            <li>
                                <div title="value">9</div>
                            </li>
                        </ul>
                    </td>
                </tr>
            </table>
        </div>
  </text>
  <identifier>
    <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-self-eve-everywoman"/>
    <display value="Eve Everywoman"/>
  </subscriber>
  <beneficiary>
    <reference value="Patient/patient-us-core-patient-eve-everywoman"/>
    <display value="Eve Everywoman"/>
  </beneficiary>
  <relationship>
    <coding>
      <code value="self"/>
    </coding>
  </relationship>
  <period>
    <start value="2019-05-23"/>
    <end value="2020-05-23"/>
  </period>
  <payor>
    <reference value="Organization/organization-bser-organization-saint-luke"/>
  </payor>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="group"/>
      </coding>
    </type>
    <value value="CB135"/>
    <name value="Corporate Baker&#39;s Inc. Local #35"/>
  </class>
  <class>
    <type>
      <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>
    </type>
    <value value="B37FC"/>
    <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="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>