CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.1.0 - STU1 Update

This page is part of the CARIN Blue Button Implementation Guide (v1.1.0: STU 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

: Coverage Example 1 - XML Representation

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<Coverage xmlns="http://hl7.org/fhir">
  <id value="CoverageEx1"/>
  <meta>
    <lastUpdated value="2020-10-30T09:48:01.8462752-04:00"/>
    <source value="Organization/PayerOrganizationExample1"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|1.1.0"/>
  </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</b></p><p><b>identifier</b>: An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501</p><p><b>status</b>: active</p><p><b>policyHolder</b>: <a href="Patient-ExamplePatient1.html">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}">unknown</span></a></p><p><b>subscriber</b>: <a href="Patient-ExamplePatient1.html">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}">unknown</span></a></p><p><b>subscriberId</b>: 888009335</p><p><b>beneficiary</b>: <a href="Patient-ExamplePatient1.html">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}">unknown</span></a></p><p><b>dependent</b>: 01</p><p><b>relationship</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}">Self</span></p><p><b>period</b>: 2020-01-01 --&gt; (ongoing)</p><p><b>payor</b>: <a href="Organization-PayerOrganizationExample1.html">UPMC Health Plan. Generated Summary: NAIC Code: 95216; active; <span title="Codes: {http://terminology.hl7.org/CodeSystem/organization-type pay}">Payer</span>; name: UPMC Health Plan; Phone: 1-844-220-4785 TTY: 711, Phone: 1-866-406-8762</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class group}">An employee group</span></p><p><b>value</b>: MCHMO1</p><p><b>name</b>: MEDICARE HMO PLAN</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class plan}">A specific suite of benefits.</span></p><p><b>value</b>: GR5</p><p><b>name</b>: GR5-HMO DEDUCTIBLE</p></blockquote><p><b>network</b>: GR5-HMO DEDUCTIBLE</p></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="MB"/>
        <display value="Member Number"/>
      </coding>
      <text
            value="An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier."/>
    </type>
    <system value="https://www.upmchealthplan.com/fhir/memberidentifier"/>
    <value value="88800933501"/>
    <assigner>
      <reference value="Organization/PayerOrganizationExample1"/>
      <display value="UPMC Health Plan"/>
    </assigner>
  </identifier>
  <status value="active"/>
  <policyHolder>
    <reference value="Patient/ExamplePatient1"/>
  </policyHolder>
  <subscriber>
    <reference value="Patient/ExamplePatient1"/>
  </subscriber>
  <subscriberId value="888009335"/>
  <beneficiary>
    <reference value="Patient/ExamplePatient1"/>
  </beneficiary>
  <dependent value="01"/>
  <relationship>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
      <code value="self"/>
    </coding>
    <text value="Self"/>
  </relationship>
  <period>
    <start value="2020-01-01"/>
  </period>
  <payor>
    <reference value="Organization/PayerOrganizationExample1"/>
    <display value="UPMC Health Plan"/>
  </payor>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="group"/>
        <display value="Group"/>
      </coding>
      <text value="An employee group"/>
    </type>
    <value value="MCHMO1"/>
    <name value="MEDICARE HMO PLAN"/>
  </class>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="plan"/>
        <display value="Plan"/>
      </coding>
      <text value="A specific suite of benefits."/>
    </type>
    <value value="GR5"/>
    <name value="GR5-HMO DEDUCTIBLE"/>
  </class>
  <network value="GR5-HMO DEDUCTIBLE"/>
</Coverage>