{

"resourceType": "CoverageEligibilityResponse",
"id": "E2501",
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/coverageeligibilityresponse",
    "value": "881234"
  }
],
"status": "active",
"purpose": [
  "validation",
  "benefits"
],
"patient": {
  "reference": "Patient/pat1"
},
"servicedDate": "2014-09-17",
"created": "2014-08-16",
"request": {
  "reference": "http://www.BenefitsInc.com/fhir/CoverageEligibilityRequest/225476332402"
},
"outcome": "complete",
"disposition": "Policy is currently in-force.",
"insurer": {
  "reference": "Organization/2"
},
"insurance": [
  {
    "coverage": {
      "reference": "Coverage/9876B1"
    },
    "inforce": true,
    "item": [
      {
        "category": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
              "code": "30",
              "display": "Health Benefit Plan Coverage"
            }
          ]
        },
        "network": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
              "code": "in"
            }
          ]
        },
        "unit": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
              "code": "individual"
            }
          ]
        },
        "term": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-term",
              "code": "annual"
            }
          ]
        },
        "benefit": [
          {
            "type": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "allowedMoney": {
              "value": 500000,
              "currency": "SAR"
            }
          },
          {
            "type": {
              "coding": [
                {
                  "code": "copay-maximum"
                }
              ]
            },
            "allowedMoney": {
              "value": 100,
              "currency": "SAR"
            }
          },
          {
            "type": {
              "coding": [
                {
                  "code": "copay-percent"
                }
              ]
            },
            "allowedUnsignedInt": 20
          }
        ]
      },
      {
        "category": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
              "code": "69",
              "display": "Maternity"
            }
          ]
        },
        "network": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
              "code": "in"
            }
          ]
        },
        "unit": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
              "code": "individual"
            }
          ]
        },
        "term": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-term",
              "code": "annual"
            }
          ]
        },
        "benefit": [
          {
            "type": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "allowedMoney": {
              "value": 15000,
              "currency": "SAR"
            }
          }
        ]
      },
      {
        "category": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
              "code": "F3",
              "display": "Dental Coverage"
            }
          ]
        },
        "network": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
              "code": "in"
            }
          ]
        },
        "unit": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
              "code": "individual"
            }
          ]
        },
        "term": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-term",
              "code": "annual"
            }
          ]
        },
        "benefit": [
          {
            "type": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "allowedMoney": {
              "value": 2000,
              "currency": "SAR"
            }
          }
        ]
      },
      {
        "category": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
              "code": "F6",
              "display": "Vision Coverage"
            }
          ]
        },
        "network": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
              "code": "in"
            }
          ]
        },
        "unit": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
              "code": "individual"
            }
          ]
        },
        "term": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-term",
              "code": "annual"
            }
          ]
        },
        "benefit": [
          {
            "type": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "allowedMoney": {
              "value": 400,
              "currency": "SAR"
            }
          }
        ]
      },
      {
        "category": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
              "code": "49",
              "display": "Hospital Room and Board"
            }
          ]
        },
        "network": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
              "code": "in"
            }
          ]
        },
        "unit": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
              "code": "individual"
            }
          ]
        },
        "term": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/benefit-term",
              "code": "day"
            }
          ]
        },
        "benefit": [
          {
            "type": {
              "coding": [
                {
                  "code": "room"
                }
              ]
            },
            "allowedString": "shared"
          },
          {
            "type": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "allowedMoney": {
              "value": 600,
              "currency": "SAR"
            }
          }
        ]
      }
    ]
  }
],
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}