FHIR IG analytics| Package | hl7.fhir.us.insurance-card |
| Resource Type | Coverage |
| Id | Coverage-Example-Coverage1.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "Coverage",
"id": "Example-Coverage1",
"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": "generated",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"extension": [
{
"url": "memberId",
"valueId": "102345672-01"
},
{
"url": "name",
"valueHumanName": {
"family": "Doe",
"given": [
"John"
]
}
}
],
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension": [
{
"url": "memberId",
"valueId": "102345672-02"
},
{
"url": "name",
"valueHumanName": {
"family": "Doe",
"given": [
"Jane"
]
}
}
],
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension": [
{
"url": "memberId",
"valueId": "102345672-03"
},
{
"url": "name",
"valueHumanName": {
"family": "Doe",
"given": [
"Jimmy"
]
}
}
],
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-PlanBeneficiaries-extension"
},
{
"extension": [
{
"url": "memberId",
"valueId": "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-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": "label",
"valueString": "ACME Inc."
},
{
"url": "description",
"valueString": "Company logo"
},
{
"url": "image",
"valueAttachment": {
"contentType": "image/png",
"data": "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"
}
}
],
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Logo-extension"
},
{
"extension": [
{
"url": "label",
"valueString": "Some lable for this QR code"
},
{
"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": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-QRCode-extension"
},
{
"extension": [
{
"url": "label",
"valueString": "Some label for this Barcode"
},
{
"url": "description",
"valueString": "Usage text for this Barcode for the end user"
},
{
"url": "image",
"valueAttachment": {
"contentType": "image/png",
"data": "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"
}
}
],
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-Barcode-extension"
},
{
"extension": [
{
"url": "label",
"valueString": "Some label text"
},
{
"url": "description",
"valueString": "Some text for the end user about the usage/meaning of this image"
},
{
"url": "image",
"valueAttachment": {
"contentType": "image/png",
"data": "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"
}
}
],
"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"
}
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code": "gpvisit"
}
]
},
"valueMoney": {
"extension": [
{
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
"valueString": "N/A"
}
]
}
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code": "spvisit"
}
]
},
"valueMoney": {
"extension": [
{
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
"valueString": "N/A"
}
]
}
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code": "emergency"
}
]
},
"valueMoney": {
"extension": [
{
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
"valueString": "N/A"
}
]
}
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/C4DICExtendedCopayTypeCS",
"code": "rx"
}
]
},
"valueMoney": {
"extension": [
{
"url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/C4DIC-BeneficiaryCostString-extension",
"valueString": "DED THEN $10/$40/$70/25%"
}
]
}
}
]
}