<?xml version=“1.0” encoding=“UTF-8”?> <Coverage xmlns=“hl7.org/fhir”>

      <id value="9876B1"/>

      <meta>
  <security>
    <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
    <code value="HTEST"/>
    <display value="test health data"/>
  </security>
</meta>

      <identifier>
              <system value="http://benefitsinc.com/certificate"/>
              <value value="12345"/>
      </identifier>

      <status value="active"/>

      <type>
              <coding>
                      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
                      <code value="EHCPOL"/>
                      <display value="extended healthcare"/>
              </coding>
      </type>

      <policyHolder>
              <reference value="http://benefitsinc.com/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>

      <payor>
              <reference value="Organization/2"/>
      </payor>

      <!--  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="CB135"/>
              <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="123"/>
              <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="B37FC"/>
              <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="P7"/>
              <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="SILVER"/>
              <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="Tier2"/>
              <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="9"/>
      </class>

      <!--  the following RX class values may be used when pharmacy claims under this coverage 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>
              <value value="MDF12345"/> <!--  member id used when submitting pharmacy claims  -->
      </class>

      <class>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                              <code value="rxbin"/>
                      </coding>
              </type>
              <value value="987654"/> <!--  the pharmacy processor BIN number used when submitting pharmacy claims  -->
      </class>

      <class>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                              <code value="rxgroup"/>
                      </coding>
              </type>
              <value value="M35PT"/> <!--  group used when submitting pharmacy claims  -->
      </class>

      <class>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                              <code value="rxpcn"/>
                      </coding>
              </type>
              <value value="234516"/> <!--  the PCN number used when submitting pharmacy claims  -->
      </class>

      <class>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                              <code value="sequence"/>
                      </coding>
              </type>
              <value value="9"/> <!--  the sequence number for a short-term continuance of the coverage  -->
      </class>

</Coverage>