Contract-example-ins-policy.json

Health Insurance Policy

{
  "resourceType": "Contract",
  "id": "INS-101",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n         <p>Plan: Your Choice Split Copay (Non-Grandfathered)</p>\n         <p>Certificate Form Number: YCSCWLN (01-2017)</p>\n      </div>"
  },
  "identifier": [
    {
      "system": "http://xyz-insurance.com/forms",
      "value": "YCSCWLN(01-2017)"
    }
  ],
  "applies": {
    "start": "2017-01-01"
  },
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/contracttypecodes",
        "code": "healthinsurance",
        "display": "Health Insurance"
      }
    ]
  },
  "term": [
    {
      "offer": {
        "text": "The benefits, limitations, exclusions and other coverage provisions in this booklet are subject to the terms of our contract with the Group. This booklet is a part of that contract, which is on file in the Group's office."
      },
      "asset": [
        {
          "class": {
            "system": "urn:ietf:rfc:3986",
            "code": "RicardianContract"
          },
          "code": {
            "display": "sample"
          },
          "period": {
            "start": "2017-06-01"
          },
          "valuedItem": [
            {
              "entityCodeableConcept": {
                "text": "Ford Bobcat"
              },
              "identifier": {
                "system": "http://somewhere.motor-vehicle.com/vin",
                "value": "XXSVT34-7665t952236"
              },
              "effectiveTime": "1995",
              "quantity": {
                "value": 1
              },
              "unitPrice": {
                "value": 200.00,
                "system": "urn:iso:std:iso:4217",
                "code": "CAD"
              },
              "factor": 1.0,
              "points": 1.0,
              "net": {
                "value": 200.00,
                "system": "urn:iso:std:iso:4217",
                "code": "CAD"
              }
            }
          ]
        }
      ],
      "group": [
        {
          "offer": {
            "text": "Eligible Providers"
          }
        },
        {
          "offer": {
            "text": "Responsibility for Payment"
          }
        },
        {
          "offer": {
            "text": "List of Benefits"
          },
          "group": [
            {
              "offer": {
                "text": "Copays"
              },
              "group": [
                {
                  "offer": {
                    "text": "Emergency Room Copay"
                  }
                },
                {
                  "offer": {
                    "text": "Professional Visit Copay"
                  }
                }
              ]
            },
            {
              "offer": {
                "text": "Calendar Year Deductible"
              }
            },
            {
              "offer": {
                "text": "Out-Of-Pocket Maximum"
              }
            },
            {
              "offer": {
                "text": "Medical Services"
              },
              "group": [
                {
                  "offer": {
                    "text": "Ambulance Services"
                  }
                },
                {
                  "offer": {
                    "text": "Dental Services"
                  }
                },
                {
                  "offer": {
                    "text": "Diagnostic Services"
                  }
                },
                {
                  "offer": {
                    "text": "Emergency Room Services"
                  }
                },
                {
                  "offer": {
                    "text": "Hospital Inpatient Care"
                  }
                }
              ]
            }
          ]
        }
      ]
    }
  ]
}