CARIN Digital Insurance Card
1.0.0 - STU 1
US
CARIN Digital Insurance Card
1.0.0 - STU 1
US
This page is part of the CARIN Digital Insurance Card (v1.0.0: STU 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
{
"resourceType" : "Coverage",
"id" : "Example-Coverage-FSH",
"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" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><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\">Resource \"Example-Coverage-FSH\" Version \"1\" 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><p><b>value</b>: 102345672-01</p><p><b>value</b>: John Doe </p></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><p><b>value</b>: 102345672-02</p><p><b>value</b>: jane Doe </p></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><p><b>value</b>: 102345672-03</p><p><b>value</b>: Jimmy Doe </p></blockquote><blockquote><p><b>Plan Beneficiaries</b></p><p><b>value</b>: 102345672-04</p><p><b>value</b>: Ginny Doe </p></blockquote><p><b>Additional Insurance Card Information</b>: 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.</p><p><b>Card Issue Date</b>: 2020-12-15</p><p><b>Background Color</b>: #00bfff <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-IECColourManagement.html\">IEC 61966-2-1: Colour measurement and management - Part 2-1: Colour management - Default RGB colour space - sRGB</a>##00bfff)</span></p><p><b>Highlight Color</b>: #ceebf5 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-IECColourManagement.html\">IEC 61966-2-1: Colour measurement and management - Part 2-1: Colour management - Default RGB colour space - sRGB</a>##ceebf5)</span></p><blockquote><p><b>Logo</b></p><p><b>value</b>: ACME Inc.</p><p><b>value</b>: Company logo</p><p><b>value</b>: </p></blockquote><blockquote><p><b>QR Code</b></p><p><b>value</b>: Some label for this QR code</p><p><b>value</b>: Usage text for this QR code for the end user</p><p><b>value</b>: </p></blockquote><blockquote><p><b>Barcode</b></p><p><b>value</b>: Some label for this Barcode</p><p><b>value</b>: Usage text for this Barcode for the end user</p><p><b>value</b>: </p></blockquote><blockquote><p><b>Supporting image</b></p><p><b>value</b>: Some label text</p><p><b>value</b>: Some text for the end user about the usage/meaning of this image</p><p><b>value</b>: </p></blockquote><p><b>identifier</b>: Member Number: 102345672-02</p><p><b>status</b>: active</p><p><b>type</b>: health insurance plan policy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-v3-ActCode.html\">ActCode</a>#HIP)</span></p><p><b>subscriber</b>: <a href=\"Patient-Example-Patient1.html\">Patient/Example-Patient1: John Doe</a> \" DOE\"</p><p><b>subscriberId</b>: 102345672-01</p><p><b>beneficiary</b>: <a href=\"Patient-Example-Patient2.html\">Patient/Example-Patient2: Jane Doe</a> \" DOE\"</p><p><b>dependent</b>: 02</p><p><b>relationship</b>: Spouse <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-subscriber-relationship.html\">SubscriberPolicyholder Relationship Codes</a>#spouse)</span></p><p><b>period</b>: 2021-01-01 --> (ongoing)</p><p><b>payor</b>: <a href=\"Organization-Example-PayerOrganization1.html\">Organization/Example-PayerOrganization1: Acme Insurance Co</a> \"Acme Insurance Co\"</p><blockquote><p><b>class</b></p><p><b>type</b>: Group <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html\">Coverage Class Codes</a>#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>: Plan <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html\">Coverage Class Codes</a>#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>: Division <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCoverageClassCS.html\">C4DIC Extended Coverage Class</a>#division)</span></p><p><b>value</b>: 11</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCoverageClassCS.html\">C4DIC Extended Coverage Class</a>#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>: RX BIN <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html\">Coverage Class Codes</a>#rxbin)</span></p><p><b>value</b>: 100045</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: RX PCN <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-coverage-class.html\">Coverage Class Codes</a>#rxpcn)</span></p><p><b>value</b>: 1234000</p></blockquote><blockquote><p><b>costToBeneficiary</b></p><p><b>type</b>: Family Out of Network Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCopayTypeCS.html\">C4DIC Extended Copay Type</a>#FamOutDed)</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>: Family In Network Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCopayTypeCS.html\">C4DIC Extended Copay Type</a>#FamInDed)</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>: Family Pharmacy Out of Network Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCopayTypeCS.html\">C4DIC Extended Copay Type</a>#FamRxOutDed)</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>: Family Pharmacy In Network Deductible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCopayTypeCS.html\">C4DIC Extended Copay Type</a>#FamRxInDed)</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>: Family Out of Network Out of Pocket Maximum <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCopayTypeCS.html\">C4DIC Extended Copay Type</a>#FamOutMax)</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>: Family In Network Out of Pocket Maximum <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCopayTypeCS.html\">C4DIC Extended Copay Type</a>#FamInMax)</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>: Family Pharmacy Out of Network Out of Pocket Maximum <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCopayTypeCS.html\">C4DIC Extended Copay Type</a>#FamRxOutMax)</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>: Family Pharmacy In Network Out of Pocket Maximum <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4DICExtendedCopayTypeCS.html\">C4DIC Extended Copay Type</a>#FamRxInMax)</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>: GP Office Visit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-coverage-copay-type.html\">Coverage Copay Type Codes</a>#gpvisit)</span></p><p><b>value</b>: </p></blockquote><p><b style=\"color: maroon\">Exception generating Narrative: null</b></p></div>"
},
"extension" : [
{
"extension" : [
{
"url" : "memberId",
"valueString" : "102345672-01"
},
{
"url" : "name",
"valueHumanName" : {
"family" : "Doe",
"given" : [
"John"
]
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension" : [
{
"url" : "memberId",
"valueString" : "102345672-02"
},
{
"url" : "name",
"valueHumanName" : {
"family" : "Doe",
"given" : [
"jane"
]
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension" : [
{
"url" : "memberId",
"valueString" : "102345672-03"
},
{
"url" : "name",
"valueHumanName" : {
"family" : "Doe",
"given" : [
"Jimmy"
]
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension" : [
{
"url" : "memberId",
"valueString" : "102345672-04"
},
{
"url" : "name",
"valueHumanName" : {
"family" : "Doe",
"given" : [
"Ginny"
]
}
}
],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-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" : "http://terminology.hl7.org/CodeSystem/IECColourManagement",
"code" : "#00bfff"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/IECColourManagement",
"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 label 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 label for this Barcode"
},
{
"url" : "description",
"valueString" : "Usage text for this Barcode 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,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "FamInDed",
"display" : "Family In Network Deductible"
}
]
},
"valueMoney" : {
"value" : 8000,
"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,
"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,
"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,
"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,
"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,
"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,
"currency" : "USD"
}
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "gpvisit"
}
]
},
"valueMoney" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
"valueString" : "N/A"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "spvisit"
}
]
},
"valueMoney" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
"valueString" : "N/A"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "emergency"
}
]
},
"valueMoney" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
"valueString" : "N/A"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS",
"code" : "rx"
}
]
},
"valueMoney" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
"valueString" : "DED THEN $10/$40/$70/25%"
}
]
}
}
]
}
IG © 2022+ HL7 Payer/Provider Information Exchange Working Group (PIE WG). Package hl7.fhir.us.insurance-card#1.0.0 based on FHIR 4.0.1. Generated 2022-07-13
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change