CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2 US

This page is part of the CARIN Blue Button Implementation Guide (v2.0.0: STU 2) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: Dental Coverage Example1 - XML Representation

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<Coverage xmlns="http://hl7.org/fhir">
  <id value="CoverageDental1"/>
  <meta>
    <lastUpdated value="2021-01-01T14:22:01.0314215+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.0.0"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative: Coverage</b><a name="CoverageDental1"> </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;CoverageDental1&quot; Updated &quot;2021-01-01 02:22:01+0000&quot;  (Language &quot;en-US&quot;) </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4BB-Coverage.html">C4BB Coverage (version 2.0.0)</a></p></div><p><b>identifier</b>: Member Number: 210300002</p><p><b>status</b>: active</p><p><b>type</b>: dental care policy <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>#DENTAL)</span></p><p><b>policyHolder</b>: <a href="Patient-Patient2.html">Patient/Patient2</a> &quot; TEST&quot;</p><p><b>subscriber</b>: <a href="Patient-Patient2.html">Patient/Patient2</a> &quot; TEST&quot;</p><p><b>subscriberId</b>: 10300007</p><p><b>beneficiary</b>: <a href="Patient-Patient2.html">Patient/Patient2</a> &quot; TEST&quot;</p><p><b>dependent</b>: 01</p><p><b>relationship</b>: Self <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-subscriber-relationship.html">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --&gt; 2021-12-31</p><p><b>payor</b>: <a href="Organization-DentalPayer1.html">Organization/DentalPayer1</a> &quot;INSURANCE COMPANY XYZ&quot;</p><blockquote><p><b>class</b></p><p><b>type</b>: An employee group <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#group)</span></p><p><b>value</b>: 10300007</p><p><b>name</b>: Transcorp - dental</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/4.0.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#plan)</span></p><p><b>value</b>: 66783JJT</p><p><b>name</b>: INSURANCE COMPANY XYZ - PRIME</p></blockquote><p><b>network</b>: INSURANCE COMPANY XYZ - PRIME</p></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="MB"/>
      </coding>
    </type>
    <system value="https://www.xxxhealthplan.com/fhir/memberidentifier"/>
    <value value="210300002"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <code value="DENTAL"/>
    </coding>
    <text value="dental care policy"/>
  </type>
  <policyHolder>
    <reference value="Patient/Patient2"/>
  </policyHolder>
  <subscriber>
    <reference value="Patient/Patient2"/>
  </subscriber>
  <subscriberId value="10300007"/>
  <beneficiary>
    <reference value="Patient/Patient2"/>
  </beneficiary>
  <dependent value="01"/>
  <relationship>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
      <code value="self"/>
    </coding>
  </relationship>
  <period>
    <start value="2021-01-01"/>
    <end value="2021-12-31"/>
  </period>
  <payor>
    <reference value="Organization/DentalPayer1"/>
  </payor>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="group"/>
      </coding>
      <text value="An employee group"/>
    </type>
    <value value="10300007"/>
    <name value="Transcorp - dental"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="plan"/>
      </coding>
      <text value="Plan"/>
    </type>
    <value value="66783JJT"/>
    <name value="INSURANCE COMPANY XYZ - PRIME"/>
  </class>
  <network value="INSURANCE COMPANY XYZ - PRIME"/>
</Coverage>