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 
<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><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.
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><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>
</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-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="http://terminology.hl7.org/CodeSystem/IECColourManagement"/>
<code value="#00bfff"/>
</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
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 label 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 label for this 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="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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"/>
<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"/>
<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"/>
<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"/>
<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"/>
<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"/>
<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"/>
<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"/>
<currency value="USD"/>
</valueMoney>
</costToBeneficiary>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="gpvisit"/>
</coding>
</type>
<valueMoney>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension">
<valueString value="N/A"/>
</extension>
</valueMoney>
</costToBeneficiary>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="spvisit"/>
</coding>
</type>
<valueMoney>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension">
<valueString value="N/A"/>
</extension>
</valueMoney>
</costToBeneficiary>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="emergency"/>
</coding>
</type>
<valueMoney>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension">
<valueString value="N/A"/>
</extension>
</valueMoney>
</costToBeneficiary>
<costToBeneficiary>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/C4DICExtendedCopayTypeCS"/>
<code value="rx"/>
</coding>
</type>
<valueMoney>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension">
<valueString value="DED THEN $10/$40/$70/25%"/>
</extension>
</valueMoney>
</costToBeneficiary>
</Coverage>
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
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