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 
<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-BeneficiaryCosts-extension">
<extension url="costToBeneficiary">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="gpvisit"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="cost">
<valueString value="N/A"/>
</extension>
</extension>
<extension url="costToBeneficiary">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="spvisit"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="cost">
<valueString value="N/A"/>
</extension>
</extension>
<extension url="costToBeneficiary">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="emergency"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="cost">
<valueString value="N/A"/>
</extension>
</extension>
<extension url="costToBeneficiary">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="urgentcare"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="cost">
<valueString value="N/A"/>
</extension>
</extension>
<extension url="costToBeneficiary">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"/>
<code value="rx"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="cost">
<valueString value="DED THEN $10/$40/$70/25%"/>
</extension>
</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-BackgroundColor-extension">
<valueCodeableConcept>
<coding>
<system
value="https://www.iso.org/standard/35883-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL"/>
<code value="#00bfff"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension">
<valueCodeableConcept>
<coding>
<system
value="https://www.iso.org/standard/35883-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL"/>
<code value="#ceebf5"/>
</coding>
</valueCodeableConcept>
</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="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"/>
</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="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"/>
</valueAttachment>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension">
<extension url="label">
<valueString value="Some lable for this Bar code"/>
</extension>
<extension url="description">
<valueString value="Usage text for this Bar code for the end user"/>
</extension>
<extension url="image">
<valueAttachment>
<contentType value="image/png"/>
<data
value="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"/>
</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="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"/>
</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://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCoverageClassCS"/>
<code value="division"/>
</coding>
</type>
<value value="11"/>
</class>
<class>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/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://hl7.org/fhir/us/insurance-card/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>
</Coverage>
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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