<?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>