CARIN Digital Insurance Card
1.1.0 - STU 1.1 United States of America flag

This page is part of the CARIN Digital Insurance Card (v1.1.0: STU1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: Coverage Example 1 - TTL Representation

Raw ttl | Download


@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Coverage ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "Example-Coverage1"] ; # 
  fhir:meta [
fhir:versionId [ fhir:v "1" ] ;
fhir:lastUpdated [ fhir:v "2021-04-06T10:49:02.473+00:00"^^xsd:dateTime ] ;
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns='http://www.w3.org/1999/xhtml'>Acme Gold Plus</div>'"
  ] ; # 
  fhir:extension ( [
    ( fhir:extension [
fhir:url [ fhir:v "memberId"^^xsd:anyURI ] ;
fhir:value [ fhir:v "102345672-01" ]     ] [
fhir:url [ fhir:v "name"^^xsd:anyURI ] ;
fhir:value [
a fhir:HumanName ;
fhir:family [ fhir:v "Doe" ] ;
        ( fhir:given [ fhir:v "John" ] )       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"^^xsd:anyURI ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "memberId"^^xsd:anyURI ] ;
fhir:value [ fhir:v "102345672-02" ]     ] [
fhir:url [ fhir:v "name"^^xsd:anyURI ] ;
fhir:value [
a fhir:HumanName ;
fhir:family [ fhir:v "Doe" ] ;
        ( fhir:given [ fhir:v "Jane" ] )       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"^^xsd:anyURI ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "memberId"^^xsd:anyURI ] ;
fhir:value [ fhir:v "102345672-03" ]     ] [
fhir:url [ fhir:v "name"^^xsd:anyURI ] ;
fhir:value [
a fhir:HumanName ;
fhir:family [ fhir:v "Doe" ] ;
        ( fhir:given [ fhir:v "Jimmy" ] )       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"^^xsd:anyURI ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "memberId"^^xsd:anyURI ] ;
fhir:value [ fhir:v "102345672-04" ]     ] [
fhir:url [ fhir:v "name"^^xsd:anyURI ] ;
fhir:value [
a fhir:HumanName ;
fhir:family [ fhir:v "Doe" ] ;
        ( fhir:given [ fhir:v "Ginny" ] )       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"^^xsd:anyURI ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:Annotation ;
fhir:text [ fhir:v "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." ]     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-CardIssueDate-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2020-12-15"^^xsd:date ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/IECColourManagement"^^xsd:anyURI ] ;
fhir:code [ fhir:v "#00bfff" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/IECColourManagement"^^xsd:anyURI ] ;
fhir:code [ fhir:v "#000000" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/IECColourManagement"^^xsd:anyURI ] ;
fhir:code [ fhir:v "#ceebf5" ]         ] )       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ColorPalette-extension"^^xsd:anyURI ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "label"^^xsd:anyURI ] ;
fhir:value [ fhir:v "ACME Inc." ]     ] [
fhir:url [ fhir:v "description"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Company logo" ]     ] [
fhir:url [ fhir:v "image"^^xsd:anyURI ] ;
fhir:value [
a fhir:Attachment ;
fhir:contentType [ fhir:v "image/png" ] ;
fhir:data [ fhir:v "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"^^xsd:base64Binary ]       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension"^^xsd:anyURI ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "label"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Some lable for this QR code" ]     ] [
fhir:url [ fhir:v "description"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Usage text for this QR code for the end user" ]     ] [
fhir:url [ fhir:v "image"^^xsd:anyURI ] ;
fhir:value [
a fhir:Attachment ;
fhir:contentType [ fhir:v "image/png" ] ;
fhir:data [ fhir:v "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"^^xsd:base64Binary ]       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension"^^xsd:anyURI ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "label"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Some label for this Barcode" ]     ] [
fhir:url [ fhir:v "description"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Usage text for this Barcode for the end user" ]     ] [
fhir:url [ fhir:v "image"^^xsd:anyURI ] ;
fhir:value [
a fhir:Attachment ;
fhir:contentType [ fhir:v "image/png" ] ;
fhir:data [ fhir:v "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"^^xsd:base64Binary ]       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension"^^xsd:anyURI ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "label"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Some label text" ]     ] [
fhir:url [ fhir:v "description"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Some text for the end user about the usage/meaning of this image" ]     ] [
fhir:url [ fhir:v "image"^^xsd:anyURI ] ;
fhir:value [
a fhir:Attachment ;
fhir:contentType [ fhir:v "image/png" ] ;
fhir:data [ fhir:v "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"^^xsd:base64Binary ]       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension"^^xsd:anyURI ]
  ] ) ; # 
  fhir:identifier ( [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ] ;
fhir:code [ fhir:v "MB" ] ;
fhir:display [ fhir:v "Member Number" ]       ] )     ] ;
fhir:system [ fhir:v "https://www.acmeinsurance.com/glossary/memberid"^^xsd:anyURI ] ;
fhir:value [ fhir:v "102345672-02" ] ;
fhir:assigner [
fhir:display [ fhir:v "Acme Insurance Co" ]     ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "HIP" ] ;
fhir:display [ fhir:v "health insurance plan policy" ]     ] ) ;
fhir:text [ fhir:v "health insurance plan policy" ]
  ] ; # 
  fhir:subscriber [
fhir:reference [ fhir:v "Patient/Example-Patient1" ] ;
fhir:display [ fhir:v "John Doe" ]
  ] ; # 
  fhir:subscriberId [ fhir:v "102345672-01"] ; # 
  fhir:beneficiary [
fhir:reference [ fhir:v "Patient/Example-Patient2" ] ;
fhir:display [ fhir:v "Jane Doe" ]
  ] ; # 
  fhir:dependent [ fhir:v "02"] ; # 
  fhir:relationship [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/subscriber-relationship"^^xsd:anyURI ] ;
fhir:code [ fhir:v "spouse" ] ;
fhir:display [ fhir:v "Spouse" ]     ] ) ;
fhir:text [ fhir:v "Spouse" ]
  ] ; # 
  fhir:period [
fhir:start [ fhir:v "2021-01-01"^^xsd:date ]
  ] ; # 
  fhir:payor ( [
fhir:reference [ fhir:v "Organization/Example-PayerOrganization1" ] ;
fhir:display [ fhir:v "Acme Insurance Co" ]
  ] ) ; # 
  fhir:class ( [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ;
fhir:code [ fhir:v "group" ]       ] )     ] ;
fhir:value [ fhir:v "993355" ] ;
fhir:name [ fhir:v "Stars Inc" ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ;
fhir:code [ fhir:v "plan" ]       ] )     ] ;
fhir:value [ fhir:v "11461128" ] ;
fhir:name [ fhir:v "Acme Gold Plus" ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCoverageClassCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "division" ]       ] )     ] ;
fhir:value [ fhir:v "11" ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCoverageClassCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "network" ]       ] )     ] ;
fhir:value [ fhir:v "561490" ] ;
fhir:name [ fhir:v "Acme Gold Plus South" ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ;
fhir:code [ fhir:v "rxbin" ]       ] )     ] ;
fhir:value [ fhir:v "100045" ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ;
fhir:code [ fhir:v "rxpcn" ]       ] )     ] ;
fhir:value [ fhir:v "1234000" ]
  ] ) ; # 
  fhir:costToBeneficiary ( [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FamOutDed" ] ;
fhir:display [ fhir:v "Family Out of Network Deductible" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
fhir:value [ fhir:v "10000.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FamInDed" ] ;
fhir:display [ fhir:v "Family In Network Deductible" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
fhir:value [ fhir:v "8000.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FamRxOutDed" ] ;
fhir:display [ fhir:v "Family Pharmacy Out of Network Deductible" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
fhir:value [ fhir:v "2000.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FamRxInDed" ] ;
fhir:display [ fhir:v "Family Pharmacy In Network Deductible" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
fhir:value [ fhir:v "1500.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FamOutMax" ] ;
fhir:display [ fhir:v "Family Out of Network Out of Pocket Maximum" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
fhir:value [ fhir:v "12000.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FamInMax" ] ;
fhir:display [ fhir:v "Family In Network Out of Pocket Maximum" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
fhir:value [ fhir:v "10000.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FamRxOutMax" ] ;
fhir:display [ fhir:v "Family Pharmacy Out of Network Out of Pocket Maximum" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
fhir:value [ fhir:v "3000.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "FamRxInMax" ] ;
fhir:display [ fhir:v "Family Pharmacy In Network Out of Pocket Maximum" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
fhir:value [ fhir:v "2000.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-copay-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "gpvisit" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
      ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "N/A" ]       ] )     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-copay-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "spvisit" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
      ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "N/A" ]       ] )     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-copay-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "emergency" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
      ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "N/A" ]       ] )     ]
  ] [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"^^xsd:anyURI ] ;
fhir:code [ fhir:v "rx" ]       ] )     ] ;
fhir:value [
a fhir:Money ;
      ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension"^^xsd:anyURI ] ;
fhir:value [ fhir:v "DED THEN $10/$40/$70/25%" ]       ] )     ]
  ] ) . #