Coverage-example-2.json

General Person Secondary Coverage Example

{
  "resourceType": "Coverage",
  "id": "7546D",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the coverage</div>"
  },
  "identifier": [
    {
      "system": "http://xyz.com/codes/identifier",
      "value": "AB98761"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "EHCPOL",
        "display": "extended healthcare"
      }
    ]
  },
  "subscriber": {
    "reference": "Patient/5"
  },
  "subscriberId": "AB9876",
  "beneficiary": {
    "reference": "Patient/5"
  },
  "dependent": "1",
  "relationship": {
    "coding": [
      {
        "code": "self"
      }
    ]
  },
  "period": {
    "start": "2011-03-17",
    "end": "2012-03-17"
  },
  "payor": [
    {
      "reference": "Organization/2"
    }
  ],
  "class": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "group"
          }
        ]
      },
      "value": "WESTAIR",
      "name": "Western Airlines"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "plan"
          }
        ]
      },
      "value": "BG4352",
      "name": "Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subplan"
          }
        ]
      },
      "value": "D15C9",
      "name": "Platinum"
    }
  ],
  "order": 2,
  "network": "5",
  "costToBeneficiary": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
            "code": "gpvisit"
          }
        ]
      },
      "valueMoney": {
        "value": 20.00,
        "currency": "USD"
      },
      "exception": [
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-coverage-financial-exception",
                "code": "retired"
              }
            ]
          },
          "period": {
            "start": "2018-01-01",
            "end": "2018-12-31"
          }
        }
      ]
    }
  ],
  "contract": [
    {
      "reference": "Contract/INS-101"
    }
  ]
}