This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v1.1.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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: coverage1001 - XML Representation

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<Coverage xmlns="http://hl7.org/fhir">
  <id value="coverage1001"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Coverage</b><a name="coverage1001"> </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;coverage1001&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-coverage.html">PCT Coverage</a></p></div><p><b>status</b>: active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>relationship</b>: Self <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-subscriber-relationship.html">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --&gt; 2022-01-01</p><p><b>payor</b>: <a href="Organization-org1001.html">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><h3>Classes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style="display: none">*</td><td>Plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#plan)</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td>Copay Percentage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-copay-type.html">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>
  </text>
  <status value="active"/>
  <subscriberId value="PFP123450000"/>
  <beneficiary>🔗 
    <reference value="Patient/patient1001"/>
  </beneficiary>
  <relationship>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
      <code value="self"/>
      <display value="Self"/>
    </coding>
  </relationship>
  <period>
    <start value="2021-01-01"/>
    <end value="2022-01-01"/>
  </period>
  <payor>🔗 
    <reference value="Organization/org1001"/>
  </payor>
  <class>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
        <code value="plan"/>
        <display value="Plan"/>
      </coding>
    </type>
    <value value="Premim Family Plus"/>
    <name value="Premim Family Plus Plan"/>
  </class>
  <costToBeneficiary>
    <type>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
        <code value="copaypct"/>
        <display value="Copay Percentage"/>
      </coding>
    </type>
    <valueQuantity>
      <value value="20"/>
    </valueQuantity>
  </costToBeneficiary>
</Coverage>