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

      <id value="E2502"/>

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

      <contained>
              <Coverage>
                      <id value="coverage-1"/>

                      <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"/>
                              </coding>
                      </type>

                      <subscriber>
                              <reference value="Patient/f201"/>
                      </subscriber>

                      <beneficiary>
                              <reference value="Patient/f201"/>
                      </beneficiary>
                      <dependent value="1"/>

                      <relationship>
                              <coding>
                                      <code value="self"/>
                              </coding>
                      </relationship>

                      <payor>
                              <identifier>
                                      <system value="http://www.bindb.com/bin"/>
                                      <value value="123456"/>
                              </identifier>
                      </payor>

                      <class>
                              <type>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
                                              <code value="EHCPOL"/>
                                      </coding>
                              </type>
                              <value value="CBI35"/>
                              <name value="Corporate Baker's Inc. Plan#35"/>
                      </class>

                      <class>
                              <type>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                                              <code value="subplan"/>
                                      </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="sequence"/>
                                      </coding>
                              </type>
                              <value value="1"/>
                      </class>

              </Coverage>
      </contained>

      <identifier>
              <system value="http://www.BenefitsInc.com/fhir/coverageeligibilityresponse"/>
              <value value="8812342"/>
      </identifier>

      <status value="active"/>

      <purpose value="validation"/>
      <purpose value="benefits"/>

      <patient>
              <reference value="Patient/f201"/>
      </patient>

      <created value="2014-09-16"/>

      <requestor>
              <identifier>
                      <system value="http://national.org/clinic"/>
                      <value value="OR1234"/>
              </identifier>   
      </requestor>

      <request>
              <reference value="http://www.BenefitsInc.com/fhir/CoverageEligibilityRequest/225476332405"/>
      </request>

      <outcome value="complete"/>

      <disposition value="Policy is currently in-force."/>

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

      <insurance>
              <coverage>
                      <reference value="#coverage-1"/>
              </coverage>

              <inforce value="true"/>

              <item>
                      <category>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
                                      <code value="30"/>
                                      <display value="Health Benefit Plan Coverage"/>
                              </coding>
                      </category>

                      <network>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
                                      <code value="in"/>
                              </coding>
                      </network>

                      <unit>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
                                      <code value="individual"/>
                              </coding>
                      </unit>

                      <term>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
                                      <code value="annual"/>
                              </coding>
                      </term>

                      <benefit>
                              <type>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </type>

                              <allowedMoney>
                                      <value value="500000"/>
                                      <currency value="USD"/> 
                              </allowedMoney>

                              <usedMoney>
                                      <value value="3748.00"/>
                                      <currency value="USD"/> 
                              </usedMoney>

                      </benefit>

                      <benefit>
                              <type>
                                      <coding>
                                              <code value="copay-maximum"/>
                                      </coding>
                              </type>

                              <allowedMoney>
                                      <value value="100"/>
                                      <currency value="USD"/> 
                              </allowedMoney>
                      </benefit>

                      <benefit>
                              <type>
                                      <coding>
                                              <code value="copay-percent"/>
                                      </coding>
                              </type>

                              <allowedUnsignedInt value="20"/>
                      </benefit>
              </item>

              <item>
                      <category>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
                                      <code value="69"/>
                                      <display value="Maternity"/>
                              </coding>
                      </category>

                      <network>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
                                      <code value="in"/>
                              </coding>
                      </network>

                      <unit>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
                                      <code value="individual"/>
                              </coding>
                      </unit>

                      <term>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
                                      <code value="annual"/>
                              </coding>
                      </term>

                      <benefit>
                              <type>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </type>

                              <allowedMoney>
                                      <value value="15000"/>
                                      <currency value="USD"/> 
                              </allowedMoney>
                      </benefit>

              </item>
              <item>
                      <category>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
                                      <code value="F3"/>
                                      <display value="Dental Coverage"/>
                              </coding>
                      </category>

                      <network>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
                                      <code value="in"/>
                              </coding>
                      </network>

                      <unit>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
                                      <code value="individual"/>
                              </coding>
                      </unit>

                      <term>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
                                      <code value="annual"/>
                              </coding>
                      </term>

                      <benefit>
                              <type>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </type>

                              <allowedMoney>
                                      <value value="2000"/>
                                      <currency value="USD"/> 
                              </allowedMoney>
                      </benefit>

              </item>
              <item>
                      <category>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
                                      <code value="F6"/>
                                      <display value="Vision Coverage"/>
                              </coding>
                      </category>

                      <excluded value="true"/> <!--  this benefit category is not covered under the plan  -->
                      <name value="Vision"/>
                      <description value="Vision products and services such as exams, glasses and contact lenses."/>

              </item>
      </insurance>

      <form>
              <coding>
                      <system value="http://national.org/form"/>
                      <code value="ELRSP/2017/01"/>
              </coding>
      </form>

</CoverageEligibilityResponse>