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

## : Example-Coverage-FSH - XML Representation

Page standards status: Informative

Raw xml | Download

    <Coverage xmlns="http://hl7.org/fhir">
      <id value="Example-Coverage-FSH"/>
      <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="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Coverage Example-Coverage-FSH</b></p><a name="Example-Coverage-FSH"> </a><a name="hcExample-Coverage-FSH"> </a><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">version: 1; Last updated: 2021-04-06 10:49:02+0000</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-C4DIC-Coverage.html">C4DIC Coverage</a></p></div><blockquote><p><b>Plan Beneficiaries</b></p><ul><li>memberId: 102345672-01</li><li>name: John Doe </li></ul></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><ul><li>memberId: 102345672-02</li><li>name: jane Doe </li></ul></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><ul><li>memberId: 102345672-03</li><li>name: Jimmy Doe </li></ul></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><ul><li>memberId: 102345672-04</li><li>name: Ginny Doe </li></ul></blockquote><p><b>Additional Insurance Card Information</b>: </p><blockquote><div><p>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.</p>
    </div></blockquote><p><b>Additional Insurance Card Information</b>: <a href="InsurancePlan-SBCExampleHMO.html">Summary of Benefits and Coverage - Acme Gold Plus HMO</a></p><p><b>Card Issue Date</b>: 2020-12-15</p><blockquote><p><b>Color Palette</b></p><ul><li>http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension: <span title="Codes:{http://terminology.hl7.org/CodeSystem/IECColourManagement #00bfff}">#00bfff</span></li><li>http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension: <span title="Codes:{http://terminology.hl7.org/CodeSystem/IECColourManagement #000000}">#000000</span></li><li>http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension: <span title="Codes:{http://terminology.hl7.org/CodeSystem/IECColourManagement #ceebf5}">#ceebf5</span></li></ul></blockquote><blockquote><p><b>Logo</b></p><ul><li>description: Company logo</li><li>image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...</li><li>label: ACME Inc.</li></ul></blockquote><blockquote><p><b>QR Code</b></p><ul><li>description: Usage text for this QR code for the end user</li><li>image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...</li><li>label: Some label for this QR code</li></ul></blockquote><blockquote><p><b>Barcode</b></p><ul><li>description: Usage text for this Barcode for the end user</li><li>image: image/png: iVBORw0KGgoAAAANSUhEUgAAABAAAAAk...</li><li>label: Some label for this Barcode</li></ul></blockquote><blockquote><p><b>Supporting image</b></p><ul><li>description: Image of the front of the member's physical insurance card showing plan name, member ID, and group number</li><li>image: image/jpeg: /9j/4AAQSkZJRgABAQEAYABgAAD/4QBo...</li><li>label: Front of insurance card</li></ul></blockquote><blockquote><p><b>Supporting image</b></p><ul><li>description: Image of the back of the member's physical insurance card showing claims address, customer service numbers, and pharmacy information</li><li>image: image/jpeg: /9j/4AAQSkZJRgABAQEAYABgAAD/4QBo...</li><li>label: Back of insurance card</li></ul></blockquote><p><b>identifier</b>: Member Number/102345672-02</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}">health insurance plan policy</span></p><p><b>subscriber</b>: <a href="Patient-Example-Patient1.html">John Doe</a></p><p><b>subscriberId</b>: 102345672-01</p><p><b>beneficiary</b>: <a href="Patient-Example-Patient2.html">Jane Doe</a></p><p><b>dependent</b>: 02</p><p><b>relationship</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship spouse}">Spouse</span></p><p><b>period</b>: 2021-01-01 --&gt; (ongoing)</p><p><b>payor</b>: <a href="Organization-Example-PayerOrganization1.html">Acme Insurance Co</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>: 993355</p><p><b>name</b>: Stars Inc</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>: 11461128</p><p><b>name</b>: Acme Gold Plus</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS division}">Division</span></p><p><b>value</b>: 11</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS network}">Network</span></p><p><b>value</b>: 561490</p><p><b>name</b>: Acme Gold Plus South</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>: 100045</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>: 1234000</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamOutDed}">Family Out of Network Deductible</span></p><p><b>value</b>: <span title="US Dollar">$10,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamInDed}">Family In Network Deductible</span></p><p><b>value</b>: <span title="US Dollar">$8,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamRxOutDed}">Family Pharmacy Out of Network Deductible</span></p><p><b>value</b>: <span title="US Dollar">$2,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamRxInDed}">Family Pharmacy In Network Deductible</span></p><p><b>value</b>: <span title="US Dollar">$1,500.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamOutMax}">Family Out of Network Out of Pocket Maximum</span></p><p><b>value</b>: <span title="US Dollar">$12,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamInMax}">Family In Network Out of Pocket Maximum</span></p><p><b>value</b>: <span title="US Dollar">$10,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamRxOutMax}">Family Pharmacy Out of Network Out of Pocket Maximum</span></p><p><b>value</b>: <span title="US Dollar">$3,000.00</span> (USD)</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS FamRxInMax}">Family Pharmacy In Network Out of Pocket Maximum</span></p><p><b>value</b>: <span title="US Dollar">$2,000.00</span> (USD)</p></blockquote></div>
      </text>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension">
        <extension url="memberId">
          <valueString 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">
          <valueString 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">
          <valueString 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">
          <valueString 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-AdditionalCardInformation-extension">
        <valueReference>🔗
          <reference value="InsurancePlan/SBCExampleHMO"/>
          <display value="Summary of Benefits and Coverage - Acme Gold Plus HMO"/>
        </valueReference>
      </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="description">
          <valueString value="Company logo"/>
        </extension>
        <extension url="image">
          <valueAttachment>
            <contentType value="image/png"/>
            <data
                  value=" "/>
          </valueAttachment>
        </extension>
        <extension url="label">
          <valueString value="ACME Inc."/>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-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 url="label">
          <valueString value="Some label for this QR code"/>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-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 url="label">
          <valueString value="Some label for this Barcode"/>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension">
        <extension url="description">
          <valueString
                       value="Image of the front of the member's physical insurance card showing plan name, member ID, and group number"/>
        </extension>
        <extension url="image">
          <valueAttachment>
            <contentType value="image/jpeg"/>
            <data
                  value=" "/>
          </valueAttachment>
        </extension>
        <extension url="label">
          <valueString value="Front of insurance card"/>
        </extension>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension">
        <extension url="description">
          <valueString
                       value="Image of the back of the member's physical insurance card showing claims address, customer service numbers, and pharmacy information"/>
        </extension>
        <extension url="image">
          <valueAttachment>
            <contentType value="image/jpeg"/>
            <data
                  value=" "/>
          </valueAttachment>
        </extension>
        <extension url="label">
          <valueString value="Back of insurance card"/>
        </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"/>
          <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"/>
          <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"/>
          <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"/>
          <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"/>
          <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"/>
          <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"/>
          <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"/>
          <currency value="USD"/>
        </valueMoney>
      </costToBeneficiary>
    </Coverage>