# Example-Coverage-FSH - CARIN Digital Insurance Card v2.0.0-ballot

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **Example-Coverage-FSH**

## Example Coverage: Example-Coverage-FSH

| |
| :--- |
| *Page standards status:*[Informative](http://hl7.org/fhir/R4/versions.html#std-process) |

version: 1; Last updated: 2021-04-06 10:49:02+0000

Profile: [C4DIC Coverage](StructureDefinition-C4DIC-Coverage.md)

> **Plan Beneficiaries**
* memberId: 102345672-01
* name: John Doe 

> **Plan Beneficiaries**
* memberId: 102345672-02
* name: jane Doe 

> **Plan Beneficiaries**
* memberId: 102345672-03
* name: Jimmy Doe 

> **Plan Beneficiaries**
* memberId: 102345672-04
* name: Ginny Doe 

**Additional Insurance Card Information**: 

> 

If you use a TTY, call 711. You may be asked to present this card when you receive care or fill a perscription. This card does not gaurentee coverage. Intentionally misusing this card may be considered fraud or a violation of the law. We encourage you to use a primary care physician as a valuable resource and personal health advocate.


**Additional Insurance Card Information**: [Summary of Benefits and Coverage - Acme Gold Plus HMO](InsurancePlan-SBCExampleHMO.md)

**Card Issue Date**: 2020-12-15

> **Color Palette**
* http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension: #00bfff
* http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension: #000000
* http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension: #ceebf5

> **Logo**
* description: Company logo
* image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...
* label: ACME Inc.

> **QR Code**
* description: Usage text for this QR code for the end user
* image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...
* label: Some label for this QR code

> **Barcode**
* description: Usage text for this Barcode for the end user
* image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...
* label: Some label for this Barcode

> **Supporting image**
* description: Image of the front of the member's physical insurance card showing plan name, member ID, and group number
* image: image/jpeg: /9j/4AAQSkZJRgABAQEAYABgAAD/4QBo...
* label: Front of insurance card

> **Supporting image**
* description: Image of the back of the member's physical insurance card showing claims address, customer service numbers, and pharmacy information
* image: image/jpeg: /9j/4AAQSkZJRgABAQEAYABgAAD/4QBo...
* label: Back of insurance card

**identifier**: Member Number/102345672-02

**status**: Active

**type**: health insurance plan policy

**subscriber**: [John Doe](Patient-Example-Patient1.md)

**subscriberId**: 102345672-01

**beneficiary**: [Jane Doe](Patient-Example-Patient2.md)

**dependent**: 02

**relationship**: Spouse

**period**: 2021-01-01 --> (ongoing)

**payor**: [Acme Insurance Co](Organization-Example-PayerOrganization1.md)

> **class****type**: Group**value**: 993355**name**: Stars Inc

> **class****type**: Plan**value**: 11461128**name**: Acme Gold Plus

> **class****type**: Division**value**: 11

> **class****type**: Network**value**: 561490**name**: Acme Gold Plus South

> **class****type**: RX BIN**value**: 100045

> **class****type**: RX PCN**value**: 1234000

> **costToBeneficiary****type**: Family Out of Network Deductible**value**: $10,000.00 (USD)

> **costToBeneficiary****type**: Family In Network Deductible**value**: $8,000.00 (USD)

> **costToBeneficiary****type**: Family Pharmacy Out of Network Deductible**value**: $2,000.00 (USD)

> **costToBeneficiary****type**: Family Pharmacy In Network Deductible**value**: $1,500.00 (USD)

> **costToBeneficiary****type**: Family Out of Network Out of Pocket Maximum**value**: $12,000.00 (USD)

> **costToBeneficiary****type**: Family In Network Out of Pocket Maximum**value**: $10,000.00 (USD)

> **costToBeneficiary****type**: Family Pharmacy Out of Network Out of Pocket Maximum**value**: $3,000.00 (USD)

> **costToBeneficiary****type**: Family Pharmacy In Network Out of Pocket Maximum**value**: $2,000.00 (USD)



## Resource Content

```json
{
  "resourceType" : "Coverage",
  "id" : "Example-Coverage-FSH",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-04-06T10:49:02.473+00:00",
    "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage"]
  },
  "extension" : [{
    "extension" : [{
      "url" : "memberId",
      "valueString" : "102345672-01"
    },
    {
      "url" : "name",
      "valueHumanName" : {
        "family" : "Doe",
        "given" : ["John"]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
  },
  {
    "extension" : [{
      "url" : "memberId",
      "valueString" : "102345672-02"
    },
    {
      "url" : "name",
      "valueHumanName" : {
        "family" : "Doe",
        "given" : ["jane"]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
  },
  {
    "extension" : [{
      "url" : "memberId",
      "valueString" : "102345672-03"
    },
    {
      "url" : "name",
      "valueHumanName" : {
        "family" : "Doe",
        "given" : ["Jimmy"]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
  },
  {
    "extension" : [{
      "url" : "memberId",
      "valueString" : "102345672-04"
    },
    {
      "url" : "name",
      "valueHumanName" : {
        "family" : "Doe",
        "given" : ["Ginny"]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
  },
  {
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension",
    "valueAnnotation" : {
      "text" : "If you use a TTY, call 711.\nYou may be asked to present this card when you receive care or fill a perscription. This card does not gaurentee coverage. Intentionally misusing this card may be considered fraud or a violation of the law.\nWe encourage you to use a primary care physician as a valuable resource and personal health advocate."
    }
  },
  {
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension",
    "valueReference" : {
      "reference" : "InsurancePlan/SBCExampleHMO",
      "display" : "Summary of Benefits and Coverage - Acme Gold Plus HMO"
    }
  },
  {
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-CardIssueDate-extension",
    "valueDate" : "2020-12-15"
  },
  {
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/IECColourManagement",
          "code" : "#00bfff"
        }]
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/IECColourManagement",
          "code" : "#000000"
        }]
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/IECColourManagement",
          "code" : "#ceebf5"
        }]
      }
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ColorPalette-extension"
  },
  {
    "extension" : [{
      "url" : "description",
      "valueString" : "Company logo"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/png",
        "data" : " "
      }
    },
    {
      "url" : "label",
      "valueString" : "ACME Inc."
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension"
  },
  {
    "extension" : [{
      "url" : "description",
      "valueString" : "Usage text for this QR code for the end user"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/png",
        "data" : " "
      }
    },
    {
      "url" : "label",
      "valueString" : "Some label for this QR code"
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension"
  },
  {
    "extension" : [{
      "url" : "description",
      "valueString" : "Usage text for this Barcode for the end user"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/png",
        "data" : " "
      }
    },
    {
      "url" : "label",
      "valueString" : "Some label for this Barcode"
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension"
  },
  {
    "extension" : [{
      "url" : "description",
      "valueString" : "Image of the front of the member's physical insurance card showing plan name, member ID, and group number"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/jpeg",
        "data" : " "
      }
    },
    {
      "url" : "label",
      "valueString" : "Front of insurance card"
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension"
  },
  {
    "extension" : [{
      "url" : "description",
      "valueString" : "Image of the back of the member's physical insurance card showing claims address, customer service numbers, and pharmacy information"
    },
    {
      "url" : "image",
      "valueAttachment" : {
        "contentType" : "image/jpeg",
        "data" : " "
      }
    },
    {
      "url" : "label",
      "valueString" : "Back of insurance card"
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension"
  }],
  "identifier" : [{
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
        "code" : "MB",
        "display" : "Member Number"
      }]
    },
    "system" : "https://www.acmeinsurance.com/glossary/memberid",
    "value" : "102345672-02",
    "assigner" : {
      "display" : "Acme Insurance Co"
    }
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
      "code" : "HIP",
      "display" : "health insurance plan policy"
    }],
    "text" : "health insurance plan policy"
  },
  "subscriber" : {
    "reference" : "Patient/Example-Patient1",
    "display" : "John Doe"
  },
  "subscriberId" : "102345672-01",
  "beneficiary" : {
    "reference" : "Patient/Example-Patient2",
    "display" : "Jane Doe"
  },
  "dependent" : "02",
  "relationship" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
      "code" : "spouse",
      "display" : "Spouse"
    }],
    "text" : "Spouse"
  },
  "period" : {
    "start" : "2021-01-01"
  },
  "payor" : [{
    "reference" : "Organization/Example-PayerOrganization1",
    "display" : "Acme Insurance Co"
  }],
  "class" : [{
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code" : "group"
      }]
    },
    "value" : "993355",
    "name" : "Stars Inc"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code" : "plan"
      }]
    },
    "value" : "11461128",
    "name" : "Acme Gold Plus"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS",
        "code" : "division"
      }]
    },
    "value" : "11"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS",
        "code" : "network"
      }]
    },
    "value" : "561490",
    "name" : "Acme Gold Plus South"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code" : "rxbin"
      }]
    },
    "value" : "100045"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code" : "rxpcn"
      }]
    },
    "value" : "1234000"
  }],
  "costToBeneficiary" : [{
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamOutDed",
        "display" : "Family Out of Network Deductible"
      }]
    },
    "valueMoney" : {
      "value" : 10000,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamInDed",
        "display" : "Family In Network Deductible"
      }]
    },
    "valueMoney" : {
      "value" : 8000,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamRxOutDed",
        "display" : "Family Pharmacy Out of Network Deductible"
      }]
    },
    "valueMoney" : {
      "value" : 2000,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamRxInDed",
        "display" : "Family Pharmacy In Network Deductible"
      }]
    },
    "valueMoney" : {
      "value" : 1500,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamOutMax",
        "display" : "Family Out of Network Out of Pocket Maximum"
      }]
    },
    "valueMoney" : {
      "value" : 12000,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamInMax",
        "display" : "Family In Network Out of Pocket Maximum"
      }]
    },
    "valueMoney" : {
      "value" : 10000,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamRxOutMax",
        "display" : "Family Pharmacy Out of Network Out of Pocket Maximum"
      }]
    },
    "valueMoney" : {
      "value" : 3000,
      "currency" : "USD"
    }
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
        "code" : "FamRxInMax",
        "display" : "Family Pharmacy In Network Out of Pocket Maximum"
      }]
    },
    "valueMoney" : {
      "value" : 2000,
      "currency" : "USD"
    }
  }]
}

```
