Health Insurance Policy (id = "INS-101")

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


   

   
      
      
         
         
      
   

   
      
      
   
   
   
      
   
   
   
      
   
   
   
      
         
         
         
      
   
   
   
      
         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.
      
      
         
            
            
            
         
         
         
            
         
         
            
         
         
            
               
            
            
               
               
            
            
            
               
            
            
               
               
            
            
            
            
               
               
            
         
      
      
         
            
         
      
      
         
            
         
      
      
         
            
         
         
            
               
            
            
               
                  
               
            
            
               
                  
               
            
         
         
            
               
            
         
         
            
               
            
         
         
            
               
            
            
               
                  
               
            
            
               
                  
               
            
            
               
                  
               
            
            
               
                  
               
            
            
               
                  
               
            
         
      
   

<Contract xmlns="http://hl7.org/fhir">
   <id value="INS-101"/> 
   <text> 
      <status value="generated"/> 
      <div xmlns="http://www.w3.org/1999/xhtml">
         <p> Plan: Your Choice Split Copay (Non-Grandfathered)</p> 
         <p> Certificate Form Number: YCSCWLN (01-2017)</p> 
      </div> 
   </text> 
   <identifier> 
      <system value="http://xyz-insurance.com/forms"/> 
      <value value="YCSCWLN(01-2017)"/> 
   </identifier> 
   
   <applies>       <start value="2017-01-01"/>    </applies> 
   
   <subject>       <reference value="Patient/1"/>    </subject> 
   
   <type>       <coding>          <system value="http://terminology.hl7.org/CodeSystem/contract-type"/>          <code value="healthinsurance"/>          <display value="Health Insurance"/>       </coding>    </type> 
   
   <term>       <offer>          <text value="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."/> 
      </offer>       <asset>          <type>             <coding>             <system value="urn:ietf:rfc:3986"/>             <code value="urn:uuid:3a48c68c-318d-4c68-8471-4a3c10fcb41b"/>             <display value="RicardianContract"/>          </coding>          </type>          <subtype>             <text value="sample"/>          </subtype>          <period>             <start value="2017-06-01"/>          </period>          <valuedItem>             <entityCodeableConcept>                <text value="Ford Bobcat"/>             </entityCodeableConcept>             <identifier>                <system value="http://somewhere.motor-vehicle.com/vin"/>                <value value="XXSVT34-7665t952236"/>             </identifier>             <effectiveTime value="1995"/>             <quantity>                <value value="1"/>             </quantity>             <unitPrice>                <value value="200.00"/>                <currency value="CAD"/>             </unitPrice>             <factor value="1.0"/>             <points value="1.0"/>             <net>                <value value="200.00"/>                <currency value="CAD"/>             </net>          </valuedItem>       </asset>       <group>          <offer>             <text value="Eligible Providers"/>          </offer>       </group>       <group>          <offer>             <text value="Responsibility for Payment"/>          </offer>       </group>       <group>          <offer>             <text value="List of Benefits"/>          </offer>          <group>             <offer>                <text value="Copays"/>             </offer>             <group>                <offer>                   <text value="Emergency Room Copay"/>                </offer>             </group>             <group>                <offer>                   <text value="Professional Visit Copay"/>                </offer>             </group>          </group>          <group>             <offer>                <text value="Calendar Year Deductible"/>             </offer>          </group>          <group>             <offer>                <text value="Out-Of-Pocket Maximum"/>             </offer>          </group>          <group>             <offer>                <text value="Medical Services"/>             </offer>             <group>                <offer>                   <text value="Ambulance Services"/>                </offer>             </group>             <group>                <offer>                   <text value="Dental Services"/>                </offer>             </group>             <group>                <offer>                   <text value="Diagnostic Services"/>                </offer>             </group>             <group>                <offer>                   <text value="Emergency Room Services"/>                </offer>             </group>             <group>                <offer>                   <text value="Hospital Inpatient Care"/>                </offer>             </group>          </group>       </group>    </term> 


</

Contract

>