R4 Draft for Comment
This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions
Eligibilityresponse-example-benefits.json

Financial Management Work Group
Maturity Level: N/A
Ballot Status: Informative
Compartments: Practitioner
Raw JSON (canonical form)
General Person Primary Coverage with Benefit Details
{
  "resourceType": "EligibilityResponse",
  "id": "E2501",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the EligibilityResponse.</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/eligibilityresponse",
      "value": "881234"
    }
  ],
  "status": "active",
  "created": "2014-08-16",
  "request": {
    "reference": "http://www.BenefitsInc.com/fhir/eligibility/225476332402"
  },
  "outcome": "complete",
  "disposition": "Policy is currently in-force.",
  "insurer": {
    "reference": "Organization/2"
  },
  "inforce": true,
  "insurance": [
    {
      "benefitBalance": [
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-category",
                "code": "medical"
              }
            ]
          },
          "subCategory": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-subcategory",
                "code": "30",
                "display": "Health Benefit Plan Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-network",
                "code": "in"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-unit",
                "code": "individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-term",
                "code": "annual"
              }
            ]
          },
          "financial": [
            {
              "type": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 500000,
                "system": "urn:iso:std:iso:4217",
                "code": "SAR"
              }
            },
            {
              "type": {
                "coding": [
                  {
                    "code": "copay-maximum"
                  }
                ]
              },
              "allowedMoney": {
                "value": 100,
                "system": "urn:iso:std:iso:4217",
                "code": "SAR"
              }
            },
            {
              "type": {
                "coding": [
                  {
                    "code": "copay-percent"
                  }
                ]
              },
              "allowedUnsignedInt": 20
            }
          ]
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-category",
                "code": "medical"
              }
            ]
          },
          "subCategory": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-subcategory",
                "code": "69",
                "display": "Maternity"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-network",
                "code": "in"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-unit",
                "code": "individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-term",
                "code": "annual"
              }
            ]
          },
          "financial": [
            {
              "type": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 15000,
                "system": "urn:iso:std:iso:4217",
                "code": "SAR"
              }
            }
          ]
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-category",
                "code": "oral"
              }
            ]
          },
          "subCategory": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-subcategory",
                "code": "F3",
                "display": "Dental Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-network",
                "code": "in"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-unit",
                "code": "individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-term",
                "code": "annual"
              }
            ]
          },
          "financial": [
            {
              "type": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 2000,
                "system": "urn:iso:std:iso:4217",
                "code": "SAR"
              }
            }
          ]
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-category",
                "code": "vision"
              }
            ]
          },
          "subCategory": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-subcategory",
                "code": "F6",
                "display": "Vision Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-network",
                "code": "in"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-unit",
                "code": "individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-term",
                "code": "annual"
              }
            ]
          },
          "financial": [
            {
              "type": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 400,
                "system": "urn:iso:std:iso:4217",
                "code": "SAR"
              }
            }
          ]
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-category",
                "code": "vision"
              }
            ]
          },
          "subCategory": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-subcategory",
                "code": "49",
                "display": "Hospital Room and Board"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-network",
                "code": "in"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-unit",
                "code": "individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/benefit-term",
                "code": "day"
              }
            ]
          },
          "financial": [
            {
              "type": {
                "coding": [
                  {
                    "code": "room"
                  }
                ]
              },
              "allowedString": "shared"
            },
            {
              "type": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 600,
                "system": "urn:iso:std:iso:4217",
                "code": "SAR"
              }
            }
          ]
        }
      ]
    }
  ]
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.