Release 4B R5 Final QA

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0-draft-final: Final QA Preview for R5 - STU see ballot notes ). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

Coverageeligibilityresponse-example-benefits.xml

Example CoverageEligibilityResponse/E2501 (XML)

Financial Management Work Group Maturity Level : N/A Standards Status : Informative Compartments : Patient , Practitioner

Raw XML ( canonical form + also see XML Format Specification )

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General Person Primary Coverage with Benefit Details (id = "E2501")

<?xml version="1.0" encoding="UTF-8"?> 
<?xml version="1.0" encoding="UTF-8"?>
<CoverageEligibilityResponse xmlns="http://hl7.org/fhir">  <id value="E2501"/>   <text>     <status value="generated"/>     <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the CoverageEligibilityResponse.</div>   </text>   <identifier>     <system value="http://www.BenefitsInc.com/fhir/coverageeligibilityresponse"/>     <value value="881234"/>   </identifier>   <status value="active"/>   <purpose value="validation"/>   <purpose value="benefits"/>   <patient>     <reference value="Patient/pat1"/>   </patient>   <servicedDate value="2014-09-17"/>    <!--   Anticipated service date   -->  <created value="2014-08-16"/>   <request>     <reference value="http://www.BenefitsInc.com/fhir/coverageeligibilityresponse/225476332402"/>   </request>   <outcome value="complete"/>   <disposition value="Policy is currently in-force."/>   <insurer>     <reference value="Organization/2"/>   </insurer>   <insurance>     <coverage>       <reference value="Coverage/9876B1"/>     </coverage>     <inforce value="true"/>     <item>       <category>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>           <code value="30"/>           <display value="Health Benefit Plan Coverage"/>         </coding>       </category>       <network>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>           <code value="in"/>         </coding>       </network>       <unit>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>           <code value="individual"/>         </coding>       </unit>       <term>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>           <code value="annual"/>         </coding>       </term>       <benefit>         <type>           <coding>             <code value="benefit"/>           </coding>         </type>         <allowedMoney>           <value value="500000"/>           <currency value="SAR"/>          </allowedMoney>       </benefit>       <benefit>         <type>           <coding>             <code value="copay-maximum"/>           </coding>         </type>         <allowedMoney>           <value value="100"/>           <currency value="SAR"/>          </allowedMoney>       </benefit>       <benefit>         <type>           <coding>             <code value="copay-percent"/>           </coding>         </type>         <allowedUnsignedInt value="20"/>       </benefit>     </item>     <item>       <category>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>           <code value="69"/>           <display value="Maternity"/>         </coding>       </category>       <network>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>           <code value="in"/>         </coding>       </network>       <unit>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>           <code value="individual"/>         </coding>       </unit>       <term>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>           <code value="annual"/>         </coding>       </term>       <benefit>         <type>           <coding>             <code value="benefit"/>           </coding>         </type>         <allowedMoney>           <value value="15000"/>           <currency value="SAR"/>          </allowedMoney>       </benefit>     </item>     <item>       <category>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>           <code value="F3"/>           <display value="Dental Coverage"/>         </coding>       </category>       <network>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>           <code value="in"/>         </coding>       </network>       <unit>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>           <code value="individual"/>         </coding>       </unit>       <term>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>           <code value="annual"/>         </coding>       </term>       <benefit>         <type>           <coding>             <code value="benefit"/>           </coding>         </type>         <allowedMoney>           <value value="2000"/>           <currency value="SAR"/>          </allowedMoney>       </benefit>     </item>     <item>       <category>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>           <code value="F6"/>           <display value="Vision Coverage"/>         </coding>       </category>       <network>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>           <code value="in"/>         </coding>       </network>       <unit>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>           <code value="individual"/>         </coding>       </unit>       <term>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>           <code value="annual"/>         </coding>       </term>       <benefit>         <type>           <coding>             <code value="benefit"/>           </coding>         </type>         <allowedMoney>           <value value="400"/>           <currency value="SAR"/>          </allowedMoney>       </benefit>     </item>     <item>       <category>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>           <code value="49"/>           <display value="Hospital Room and Board"/>         </coding>       </category>       <network>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>           <code value="in"/>         </coding>       </network>       <unit>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>           <code value="individual"/>         </coding>       </unit>       <term>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>           <code value="day"/>         </coding>       </term>       <benefit>         <type>           <coding>             <code value="room"/>           </coding>         </type>         <allowedString value="shared"/>       </benefit>       <benefit>         <type>           <coding>             <code value="benefit"/>           </coding>         </type>         <allowedMoney>           <value value="600"/>           <currency value="SAR"/>          </allowedMoney>       </benefit>     </item>   </insurance> 


</

CoverageEligibilityResponse

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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.