HL7.FHIR.US.DME-ORDERS\Coverage - XML Representation

This page is part of the Post Acute Orders FHIR IG (v0.2.0: STU 1 Ballot 2) based on FHIR R4. . For a full list of available versions, see the Directory of published versions
: Coverage - XML Representation

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<Coverage xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <meta>
    <versionId value="8"/>
    <lastUpdated value="2020-08-09T23:27:39.427+00:00"/>
    <source value="#QPwVk0hKzW9hvHtn"/>
    <profile
             value="http://hl7.org/fhir/us/dme-orders/StructureDefinition/PAOX-coverage"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: example</p><p><b>meta</b>: </p><p><b>identifier</b>: id: 12345</p><p><b>status</b>: active</p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ActCode EHCPOL}">extended healthcare</span></p><p><b>subscriber</b>: <a href="Patient-example1.html">Generated Summary: id: example1; Medical Record Number: 1032702 (USUAL); active; Amy V. Shaw , Amy V. Baxter ; ph: 555-555-5555(HOME); gender: female; birthDate: 1987-02-20</a></p><p><b>beneficiary</b>: <a href="Patient-example1.html">Generated Summary: id: example1; Medical Record Number: 1032702 (USUAL); active; Amy V. Shaw , Amy V. Baxter ; ph: 555-555-5555(HOME); gender: female; birthDate: 1987-02-20</a></p><p><b>dependent</b>: 0</p><p><b>relationship</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}">Self</span></p><p><b>period</b>: 2011-05-23 --&gt; 2012-05-23</p><p><b>payor</b>: <a href="Organization-Inpatient.html">Generated Summary: id: Inpatient; id: 1063494177; active; name: St. Michael's Hospital; ph: (816)932-2000(WORK), http://www.stmichaelmedicalcenter.org(WORK)</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class group}">Group</span></p><p><b>value</b>: CB135</p><p><b>name</b>: Corporate Baker's Inc. Local #35</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class subgroup}">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>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class plan}">Plan</span></p><p><b>value</b>: B37FC</p><p><b>name</b>: Full Coverage: Medical, Dental, Pharmacy, Vision, EHC</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class subplan}">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>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class class}">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>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class subclass}">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>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class sequence}">Sequence</span></p><p><b>value</b>: 9</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class rxid}">RX Id</span></p><p><b>value</b>: MDF12345</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class rxbin}">RX BIN</span></p><p><b>value</b>: 987654</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class rxgroup}">RX Group</span></p><p><b>value</b>: M35PT</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class rxpcn}">RX PCN</span></p><p><b>value</b>: 234516</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/coverage-class sequence}">Sequence</span></p><p><b>value</b>: 9</p></blockquote></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="Patient/example1"/>
  </subscriber>
  <beneficiary>
    <reference value="Patient/example1"/>
  </beneficiary>
  <dependent value="0"/>
  <relationship>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
      <code value="self"/>
    </coding>
  </relationship>
  <period>
    <start value="2011-05-23"/>
    <end value="2012-05-23"/>
  </period>
  <payor>
    <reference value="Organization/Inpatient"/>
  </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>