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 Example 1 - XML Representation

Raw xml | Download



<Coverage xmlns="http://hl7.org/fhir">
  <id value="Example-Coverage1"/>
  <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="generated"/>
    <div xmlns='http://www.w3.org/1999/xhtml'>Acme Gold Plus</div>'
  </text>
  <extension
             url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension">
    <extension url="memberId">
      <valueId 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">
      <valueId 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">
      <valueId 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">
      <valueId 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 lable 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="10000.00"/>
      <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="8000.00"/>
      <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="2000.00"/>
      <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="1500.00"/>
      <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="12000.00"/>
      <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="10000.00"/>
      <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="3000.00"/>
      <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="2000.00"/>
      <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>