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Source1

{
  "resourceType": "Coverage",
  "id": "Example-Coverage-FSH",
  "meta": {
    "versionId": "1",
    "lastUpdated": "2021-04-06T10:49:02.473+00:00",
    "profile": [
      "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Coverage"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "extension": [
        {
          "url": "memberId",
          "valueString": "102345672-01"
        },
        {
          "url": "name",
          "valueHumanName": {
            "family": "Doe",
            "given": [
              "John"
            ]
          }
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
    },
    {
      "extension": [
        {
          "url": "memberId",
          "valueString": "102345672-02"
        },
        {
          "url": "name",
          "valueHumanName": {
            "family": "Doe",
            "given": [
              "jane"
            ]
          }
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
    },
    {
      "extension": [
        {
          "url": "memberId",
          "valueString": "102345672-03"
        },
        {
          "url": "name",
          "valueHumanName": {
            "family": "Doe",
            "given": [
              "Jimmy"
            ]
          }
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
    },
    {
      "extension": [
        {
          "url": "memberId",
          "valueString": "102345672-04"
        },
        {
          "url": "name",
          "valueHumanName": {
            "family": "Doe",
            "given": [
              "Ginny"
            ]
          }
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
    },
    {
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension",
      "valueAnnotation": {
        "text": "If you use a TTY, call 711.\nYou 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.\nWe encourage you to use a primary care physician as a valuable resource and personal health advocate."
      }
    },
    {
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-AdditionalCardInformation-extension",
      "valueReference": {
        "reference": "InsurancePlan/SBCExampleHMO",
        "display": "Summary of Benefits and Coverage - Acme Gold Plus HMO"
      }
    },
    {
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-CardIssueDate-extension",
      "valueDate": "2020-12-15"
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BackgroundColor-extension",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/IECColourManagement",
                "code": "#00bfff"
              }
            ]
          }
        },
        {
          "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ForegroundColor-extension",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/IECColourManagement",
                "code": "#000000"
              }
            ]
          }
        },
        {
          "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-HighlightColor-extension",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/IECColourManagement",
                "code": "#ceebf5"
              }
            ]
          }
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-ColorPalette-extension"
    },
    {
      "extension": [
        {
          "url": "description",
          "valueString": "Company logo"
        },
        {
          "url": "image",
          "valueAttachment": {
            "contentType": "image/png",
            "data": "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"
          }
        },
        {
          "url": "label",
          "valueString": "ACME Inc."
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension"
    },
    {
      "extension": [
        {
          "url": "description",
          "valueString": "Usage text for this QR code for the end user"
        },
        {
          "url": "image",
          "valueAttachment": {
            "contentType": "image/png",
            "data": "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"
          }
        },
        {
          "url": "label",
          "valueString": "Some label for this QR code"
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension"
    },
    {
      "extension": [
        {
          "url": "description",
          "valueString": "Usage text for this Barcode for the end user"
        },
        {
          "url": "image",
          "valueAttachment": {
            "contentType": "image/png",
            "data": "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"
          }
        },
        {
          "url": "label",
          "valueString": "Some label for this Barcode"
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension"
    },
    {
      "extension": [
        {
          "url": "description",
          "valueString": "Some text for the end user about the usage/meaning of this image"
        },
        {
          "url": "image",
          "valueAttachment": {
            "contentType": "image/png",
            "data": "iVBORw0KGgoAAAANSUhEUgAAABAAAAAkCAQAAAAqEXJRAAAABGdBTUEAALGPC/xhBQAAACBjSFJNAAB6JgAAgIQAAPoAAACA6AAAdTAAAOpgAAA6mAAAF3CculE8AAAAAmJLR0QA/4ePzL8AAAAHdElNRQflCBoOCChye9NTAAAAsklEQVQ4y+WSsQrCMBCGv9ZCUdwUBEcfR+c+kVPewHdxdxEcBQW1FBTpkFoQ6iJxiSHaRCdB9L/l5+6/kP/uAHpMOKCeYoegDdBlUyveY06zwZghPvQpYe3tVyhmARdi/DhGVvnEVLMRLc1irOcWRpqanAx5g98QRI6WhI6dsAcVkrB82IW0BTmr2rJkgHr5heIzNgsqv+CMYEDutlkh9ARSt81/PpjvONqt4XvDMq6alTdjhHqxFxxRQAAAACV0RVh0ZGF0ZTpjcmVhdGUAMjAyMS0wOC0yNlQxNDowODo0MCswMDowMF+TI3oAAAAldEVYdGRhdGU6bW9kaWZ5ADIwMjEtMDgtMjZUMTQ6MDg6NDArMDA6MDAuzpvGAAAAAElFTkSuQmCC"
          }
        },
        {
          "url": "label",
          "valueString": "Some label text"
        }
      ],
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-SupportingImage-extension"
    }
  ],
  "identifier": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code": "MB",
            "display": "Member Number"
          }
        ]
      },
      "system": "https://www.acmeinsurance.com/glossary/memberid",
      "value": "102345672-02",
      "assigner": {
        "display": "Acme Insurance Co"
      }
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "HIP",
        "display": "health insurance plan policy"
      }
    ],
    "text": "health insurance plan policy"
  },
  "subscriber": {
    "reference": "Patient/Example-Patient1",
    "display": "John Doe"
  },
  "subscriberId": "102345672-01",
  "beneficiary": {
    "reference": "Patient/Example-Patient2",
    "display": "Jane Doe"
  },
  "dependent": "02",
  "relationship": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
        "code": "spouse",
        "display": "Spouse"
      }
    ],
    "text": "Spouse"
  },
  "period": {
    "start": "2021-01-01"
  },
  "payor": [
    {
      "reference": "Organization/Example-PayerOrganization1",
      "display": "Acme Insurance Co"
    }
  ],
  "class": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "group"
          }
        ]
      },
      "value": "993355",
      "name": "Stars Inc"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "plan"
          }
        ]
      },
      "value": "11461128",
      "name": "Acme Gold Plus"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS",
            "code": "division"
          }
        ]
      },
      "value": "11"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCoverageClassCS",
            "code": "network"
          }
        ]
      },
      "value": "561490",
      "name": "Acme Gold Plus South"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxbin"
          }
        ]
      },
      "value": "100045"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxpcn"
          }
        ]
      },
      "value": "1234000"
    }
  ],
  "costToBeneficiary": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
            "code": "FamOutDed",
            "display": "Family Out of Network Deductible"
          }
        ]
      },
      "valueMoney": {
        "value": 10000,
        "currency": "USD"
      }
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
            "code": "FamInDed",
            "display": "Family In Network Deductible"
          }
        ]
      },
      "valueMoney": {
        "value": 8000,
        "currency": "USD"
      }
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
            "code": "FamRxOutDed",
            "display": "Family Pharmacy Out of Network Deductible"
          }
        ]
      },
      "valueMoney": {
        "value": 2000,
        "currency": "USD"
      }
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
            "code": "FamRxInDed",
            "display": "Family Pharmacy In Network Deductible"
          }
        ]
      },
      "valueMoney": {
        "value": 1500,
        "currency": "USD"
      }
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
            "code": "FamOutMax",
            "display": "Family Out of Network Out of Pocket Maximum"
          }
        ]
      },
      "valueMoney": {
        "value": 12000,
        "currency": "USD"
      }
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
            "code": "FamInMax",
            "display": "Family In Network Out of Pocket Maximum"
          }
        ]
      },
      "valueMoney": {
        "value": 10000,
        "currency": "USD"
      }
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
            "code": "FamRxOutMax",
            "display": "Family Pharmacy Out of Network Out of Pocket Maximum"
          }
        ]
      },
      "valueMoney": {
        "value": 3000,
        "currency": "USD"
      }
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
            "code": "FamRxInMax",
            "display": "Family Pharmacy In Network Out of Pocket Maximum"
          }
        ]
      },
      "valueMoney": {
        "value": 2000,
        "currency": "USD"
      }
    }
  ]
}