CARIN Digital Insurance Card
0.1.0 - STU 1 Ballot
CARIN Digital Insurance Card
0.1.0 - STU 1 Ballot
This page is part of the CARIN Digital Insurance Card (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
{
"resourceType" : "Coverage",
"id" : "Example-Coverage1",
"meta" : {
"versionId" : "1",
"lastUpdated" : "2021-04-06T10:49:02.473+00:00",
"profile" : [
"http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>Acme Gold Plus</div>'"
},
"extension" : [
{
"extension" : [
{
"url" : "memberId",
"valueId" : "102345672-01"
},
{
"url" : "name",
"valueHumanName" : {
"family" : "Doe",
"given" : [
"John"
]
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension" : [
{
"url" : "memberId",
"valueId" : "102345672-02"
},
{
"url" : "name",
"valueHumanName" : {
"family" : "Doe",
"given" : [
"Jane"
]
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension" : [
{
"url" : "memberId",
"valueId" : "102345672-03"
},
{
"url" : "name",
"valueHumanName" : {
"family" : "Doe",
"given" : [
"Jimmy"
]
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension" : [
{
"url" : "memberId",
"valueId" : "102345672-04"
},
{
"url" : "name",
"valueHumanName" : {
"family" : "Doe",
"given" : [
"Ginny"
]
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension" : [
{
"extension" : [
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "gpvisit"
}
]
}
},
{
"url" : "cost",
"valueString" : "N/A"
}
],
"url" : "costToBeneficiary"
},
{
"extension" : [
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "spvisit"
}
]
}
},
{
"url" : "cost",
"valueString" : "N/A"
}
],
"url" : "costToBeneficiary"
},
{
"extension" : [
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "emergency"
}
]
}
},
{
"url" : "cost",
"valueString" : "N/A"
}
],
"url" : "costToBeneficiary"
},
{
"extension" : [
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "urgentcare"
}
]
}
},
{
"url" : "cost",
"valueString" : "N/A"
}
],
"url" : "costToBeneficiary"
},
{
"extension" : [
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "rx"
}
]
}
},
{
"url" : "cost",
"valueString" : "DED THEN $10/$40/$70/25%"
}
],
"url" : "costToBeneficiary"
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCosts-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-CardIssueDate-extension",
"valueDate" : "2020-12-15"
},
{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.iso.org/standard/35883-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL",
"code" : "#00bfff"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.iso.org/standard/35883-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL",
"code" : "#ceebf5"
}
]
}
},
{
"extension" : [
{
"url" : "label",
"valueString" : "ACME Inc."
},
{
"url" : "description",
"valueString" : "Company logo"
},
{
"url" : "image",
"valueAttachment" : {
"contentType" : "image/png",
"data" : "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"
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension"
},
{
"extension" : [
{
"url" : "label",
"valueString" : "Some lable for this QR code"
},
{
"url" : "description",
"valueString" : "Usage text for this QR code for the end user"
},
{
"url" : "image",
"valueAttachment" : {
"contentType" : "image/png",
"data" : "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"
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension"
},
{
"extension" : [
{
"url" : "label",
"valueString" : "Some lable for this Bar code"
},
{
"url" : "description",
"valueString" : "Usage text for this Bar code for the end user"
},
{
"url" : "image",
"valueAttachment" : {
"contentType" : "image/png",
"data" : "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"
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension"
},
{
"extension" : [
{
"url" : "label",
"valueString" : "Some label text"
},
{
"url" : "description",
"valueString" : "Some text for the end user about the usage/meaning of this image"
},
{
"url" : "image",
"valueAttachment" : {
"contentType" : "image/png",
"data" : "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"
}
}
],
"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://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCoverageClassCS",
"code" : "division"
}
]
},
"value" : "11"
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamOutDed",
"display" : "Family Out of Network Deductible"
}
]
},
"valueMoney" : {
"value" : 10000.00,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamInDed",
"display" : "Family In Network Deductible"
}
]
},
"valueMoney" : {
"value" : 8000.00,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamRxOutDed",
"display" : "Family Pharmacy Out of Network Deductible"
}
]
},
"valueMoney" : {
"value" : 2000.00,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamRxInDed",
"display" : "Family Pharmacy In Network Deductible"
}
]
},
"valueMoney" : {
"value" : 1500.00,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamOutMax",
"display" : "Family Out of Network Out of Pocket Maximum"
}
]
},
"valueMoney" : {
"value" : 12000.00,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamInMax",
"display" : "Family In Network Out of Pocket Maximum"
}
]
},
"valueMoney" : {
"value" : 10000.00,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamRxOutMax",
"display" : "Family Pharmacy Out of Network Out of Pocket Maximum"
}
]
},
"valueMoney" : {
"value" : 3000.00,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamRxInMax",
"display" : "Family Pharmacy In Network Out of Pocket Maximum"
}
]
},
"valueMoney" : {
"value" : 2000.00,
"currency" : "USD"
}
}
]
}
IG © 2021+ HL7 Payer/Provider Information Exchange Working Group (PIE WG). Package hl7.fhir.us.insurance-card#0.1.0 based on FHIR 4.0.1. Generated 2021-12-06
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