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

      <id value="7546D"/>

      <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://xyz.com/codes/identifier"/>
              <value value="AB98761"/>
      </identifier>

      <status value="active"/>

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

      <subscriber>
              <reference value="Patient/5"/>
      </subscriber>

      <subscriberId value="AB9876"/>

      <beneficiary>
              <reference value="Patient/5"/>
      </beneficiary>

      <dependent value="1"/>

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

      <period> 
              <start value="2011-03-17"/>
              <end value="2012-03-17"/>
      </period>

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

      <class>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                              <code value="group"/>
                      </coding>
              </type>
              <value value="WESTAIR"/>
              <name value="Western Airlines"/>
      </class>

      <class>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                              <code value="plan"/>
                      </coding>
              </type>
              <value value="BG4352"/>
              <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="D15C9"/>
              <name value="Platinum"/>
      </class>

      <order value="2"/> <!--  Second after the national medical coverage  -->

      <network value="5"/>

      <costToBeneficiary>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
                              <code value="gpvisit"/> <!--  normally $40.00  -->
                      </coding>
              </type>
              <valueMoney>
                      <value value="20.00"/>
                      <currency value="USD"/>
              </valueMoney>
              <exception>
                      <type>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-coverage-financial-exception"/>
                                      <code value="retired"/>
                              </coding>
                      </type>
                      <period>
                              <start value="2018-01-01"/>
                              <end value="2018-12-31"/>
                      </period>
              </exception>
      </costToBeneficiary>

      <contract>
              <reference value="Contract/INS-101"/>
      </contract>

</Coverage>