CARIN Digital Insurance Card
2.0.0-ballot - STU 2 Ballot

CARIN Digital Insurance Card - Downloaded Version 2.0.0-ballot See the Directory of published versions

## : Coverage Example 1 - XML Representation

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    <Coverage xmlns="http://hl7.org/fhir">
      <id value="Example-Coverage1"/>
      <meta>
        <versionId value="1"/>
        <lastUpdated value="2021-04-06T10:49:02.473+00:00"/>
        <profile
                 value="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage"/>
      </meta>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">Acme Gold Plus</div>
      </text>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension">
        <extension url="memberId">
          <valueId value="102345672-01"/>
        </extension>
        <extension url="name">
          <valueHumanName>
            <family value="Doe"/>
            <given value="John"/>
          </valueHumanName>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension">
        <extension url="memberId">
          <valueId value="102345672-02"/>
        </extension>
        <extension url="name">
          <valueHumanName>
            <family value="Doe"/>
            <given value="Jane"/>
          </valueHumanName>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension">
        <extension url="memberId">
          <valueId value="102345672-03"/>
        </extension>
        <extension url="name">
          <valueHumanName>
            <family value="Doe"/>
            <given value="Jimmy"/>
          </valueHumanName>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension">
        <extension url="memberId">
          <valueId value="102345672-04"/>
        </extension>
        <extension url="name">
          <valueHumanName>
            <family value="Doe"/>
            <given value="Ginny"/>
          </valueHumanName>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension">
        <valueAnnotation>
          <text
                value="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."/>
        </valueAnnotation>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-CardIssueDate-extension">
        <valueDate value="2020-12-15"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ColorPalette-extension">
        <extension
                   url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/IECColourManagement"/>
              <code value="#00bfff"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/IECColourManagement"/>
              <code value="#000000"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/IECColourManagement"/>
              <code value="#ceebf5"/>
            </coding>
          </valueCodeableConcept>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension">
        <extension url="label">
          <valueString value="ACME Inc."/>
        </extension>
        <extension url="description">
          <valueString value="Company logo"/>
        </extension>
        <extension url="image">
          <valueAttachment>
            <contentType value="image/png"/>
            <data
                  value=" "/>
          </valueAttachment>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension">
        <extension url="label">
          <valueString value="Some lable for this QR code"/>
        </extension>
        <extension url="description">
          <valueString value="Usage text for this QR code for the end user"/>
        </extension>
        <extension url="image">
          <valueAttachment>
            <contentType value="image/png"/>
            <data
                  value=" "/>
          </valueAttachment>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension">
        <extension url="label">
          <valueString value="Some label for this Barcode"/>
        </extension>
        <extension url="description">
          <valueString value="Usage text for this Barcode for the end user"/>
        </extension>
        <extension url="image">
          <valueAttachment>
            <contentType value="image/png"/>
            <data
                  value=" "/>
          </valueAttachment>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension">
        <extension url="label">
          <valueString value="Some label text"/>
        </extension>
        <extension url="description">
          <valueString
                       value="Some text for the end user about the usage/meaning of this image"/>
        </extension>
        <extension url="image">
          <valueAttachment>
            <contentType value="image/png"/>
            <data
                  value=" "/>
          </valueAttachment>
        </extension>
      </extension>
      <identifier>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
            <code value="MB"/>
            <display value="Member Number"/>
          </coding>
        </type>
        <system value="https://www.acmeinsurance.com/glossary/memberid"/>
        <value value="102345672-02"/>
        <assigner>
          <display value="Acme Insurance Co"/>
        </assigner>
      </identifier>
      <status value="active"/>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
          <code value="HIP"/>
          <display value="health insurance plan policy"/>
        </coding>
        <text value="health insurance plan policy"/>
      </type>
      <subscriber>🔗
        <reference value="Patient/Example-Patient1"/>
        <display value="John Doe"/>
      </subscriber>
      <subscriberId value="102345672-01"/>
      <beneficiary>🔗
        <reference value="Patient/Example-Patient2"/>
        <display value="Jane Doe"/>
      </beneficiary>
      <dependent value="02"/>
      <relationship>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
          <code value="spouse"/>
          <display value="Spouse"/>
        </coding>
        <text value="Spouse"/>
      </relationship>
      <period>
        <start value="2021-01-01"/>
      </period>
      <payor>🔗
        <reference value="Organization/Example-PayerOrganization1"/>
        <display value="Acme Insurance Co"/>
      </payor>
      <class>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
            <code value="group"/>
          </coding>
        </type>
        <value value="993355"/>
        <name value="Stars Inc"/>
      </class>
      <class>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
            <code value="plan"/>
          </coding>
        </type>
        <value value="11461128"/>
        <name value="Acme Gold Plus"/>
      </class>
      <class>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS"/>
            <code value="division"/>
          </coding>
        </type>
        <value value="11"/>
      </class>
      <class>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS"/>
            <code value="network"/>
          </coding>
        </type>
        <value value="561490"/>
        <name value="Acme Gold Plus South"/>
      </class>
      <class>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
            <code value="rxbin"/>
          </coding>
        </type>
        <value value="100045"/>
      </class>
      <class>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
            <code value="rxpcn"/>
          </coding>
        </type>
        <value value="1234000"/>
      </class>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="FamOutDed"/>
            <display value="Family Out of Network Deductible"/>
          </coding>
        </type>
        <valueMoney>
          <value value="10000.00"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="FamInDed"/>
            <display value="Family In Network Deductible"/>
          </coding>
        </type>
        <valueMoney>
          <value value="8000.00"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="FamRxOutDed"/>
            <display value="Family Pharmacy Out of Network Deductible"/>
          </coding>
        </type>
        <valueMoney>
          <value value="2000.00"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="FamRxInDed"/>
            <display value="Family Pharmacy In Network Deductible"/>
          </coding>
        </type>
        <valueMoney>
          <value value="1500.00"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="FamOutMax"/>
            <display value="Family Out of Network Out of Pocket Maximum"/>
          </coding>
        </type>
        <valueMoney>
          <value value="12000.00"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="FamInMax"/>
            <display value="Family In Network Out of Pocket Maximum"/>
          </coding>
        </type>
        <valueMoney>
          <value value="10000.00"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="FamRxOutMax"/>
            <display
                     value="Family Pharmacy Out of Network Out of Pocket Maximum"/>
          </coding>
        </type>
        <valueMoney>
          <value value="3000.00"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="FamRxInMax"/>
            <display value="Family Pharmacy In Network Out of Pocket Maximum"/>
          </coding>
        </type>
        <valueMoney>
          <value value="2000.00"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
            <code value="gpvisit"/>
          </coding>
        </type>
        <valueMoney>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension">
            <valueString value="N/A"/>
          </extension>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
            <code value="spvisit"/>
          </coding>
        </type>
        <valueMoney>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension">
            <valueString value="N/A"/>
          </extension>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
            <code value="emergency"/>
          </coding>
        </type>
        <valueMoney>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension">
            <valueString value="N/A"/>
          </extension>
        </valueMoney>
      </costToBeneficiary>
      <costToBeneficiary>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS"/>
            <code value="rx"/>
          </coding>
        </type>
        <valueMoney>
          <extension
                     url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension">
            <valueString value="DED THEN $10/$40/$70/25%"/>
          </extension>
        </valueMoney>
      </costToBeneficiary>
    </Coverage>