R6 Ballot (3rd Draft) (1st Full Ballot)

Publish-box (todo) This page is part of the FHIR Specification v6.0.0-ballot4: Release 6 Ballot (1st Full Ballot) (see Ballot Notes ). The current version is 5.0.0 . For a full list of available versions, see the Directory of published versions for published versions

Example Coverage/9876B1 (XML)

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

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

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General Person Primary Coverage Example (id = "9876B1") 

<?xml version="1.0" encoding="UTF-8"?>

  
  
    
  
  
    
    
  
  
  
  
    
      
      
      
    
  
  
    
  
  
    
  
  
    
  
  
  
    
      
    
  
  
    
    
  
  
    
  

<Coverage xmlns="http://hl7.org/fhir">
  <id value="9876B1"/> 
  <text> 
    <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the coverage</div> 
  </text> 
  <identifier> 
    <system value="http://benefitsinc.com/certificate"/> 
    <value value="12345"/> 
  </identifier> 
  <status value="active"/> 
  <kind value="insurance"/> 
  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> 
      <code value="EHCPOL"/> 
      <display value="extended healthcare"/> 
    </coding> 
  </type> 
  <policyHolder> 
    <reference value="http://benefits.example.org/FHIR/Organization/CBI35"/> 
  </policyHolder> 
  <subscriber> 
    <reference value="Patient/4"/> 
  </subscriber> 
  <beneficiary> 
    <reference value="Patient/4"/> 
  </beneficiary> 
  <dependent value="0"/> 
  <relationship> 
    <coding> 
      <code value="self"/> 
    </coding> 
  </relationship> 
  <period> 
    <start value="2011-05-23"/> 
    <end value="2012-05-23"/> 
  </period> 
  <insurer> 
    <reference value="Organization/2"/> 
  </insurer> 
  <!--   The repeating 'class' element is proposed to replace the 'grouping' element 
    -->
  
    
      
        
        
      
    
    
      
    
    
  
  
    
      
        
        
      
    
    
      
    
    
  
  
    
      
        
        
      
    
    
      
    
    
  
  
    
      
        
        
      
    
    
      
    
    
  
  
    
      
        
        
      
    
    
      
    
    
  
  
    
      
        
        
      
    
    
      
    
    
  
  
    
      
        
        
      
    
    
      
    
  

    -->
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="group"/> 
      </coding> 
    </type> 
    <value> 
      <value value="CB135"/> 
    </value> 
    <name value="Corporate Baker's Inc. Local #35"/> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="subgroup"/> 
      </coding> 
    </type> 
    <value> 
      <value value="123"/> 
    </value> 
    <name value="Trainee Part-time Benefits"/> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="plan"/> 
      </coding> 
    </type> 
    <value> 
      <value value="B37FC"/> 
    </value> 
    <name value="Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"/> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="subplan"/> 
      </coding> 
    </type> 
    <value> 
      <value value="P7"/> 
    </value> 
    <name value="Includes afterlife benefits"/> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="class"/> 
      </coding> 
    </type> 
    <value> 
      <value value="SILVER"/> 
    </value> 
    <name value="Silver: Family Plan spouse only"/> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="subclass"/> 
      </coding> 
    </type> 
    <value> 
      <value value="Tier2"/> 
    </value> 
    <name value="Low deductable, max $20 copay"/> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="sequence"/> 
      </coding> 
    </type> 
    <value> 
      <value value="9"/> 
    </value> 
  </class> 
  <!--   the following RX class values may be used when pharmacy claims under this coverage
   are sent to a pharmacy claim only processor   -->
  
    
      
        
        
      
    
    
    
      
    
  
  
    
      
        
        
      
    
    
    
      
    
  
  
    
      
        
        
      
    
    
    
      
    
  
  
    
      
        
        
      
    
    
    
      
    
  
  
    
      
        
        
      
    
    
    
      
    
  

   are sent to a pharmacy claim only processor   -->
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="rxid"/> 
      </coding> 
    </type> 
    <!--   member id used when submitting pharmacy claims   -->
    <value> 
      <value value="MDF12345"/> 
    </value> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="rxbin"/> 
      </coding> 
    </type> 
    <!--   the pharmacy processor BIN number used when submitting pharmacy claims   -->
    <value> 
      <value value="987654"/> 
    </value> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="rxgroup"/> 
      </coding> 
    </type> 
    <!--   group used when submitting pharmacy claims   -->
    <value> 
      <value value="M35PT"/> 
    </value> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="rxpcn"/> 
      </coding> 
    </type> 
    <!--   the PCN number used when submitting pharmacy claims   -->
    <value> 
      <value value="234516"/> 
    </value> 
  </class> 
  <class> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> 
        <code value="sequence"/> 
      </coding> 
    </type> 
    <!--   the sequence number for a short-term continuance of the coverage   -->
    <value> 
      <value value="9"/> 
    </value> 
  </class> 


</

Coverage

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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.