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

<id value="E2501"/>

<text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the EligibilityResponse.</div>
</text>

<identifier>
        <system value="http://www.BenefitsInc.com/fhir/eligibilityresponse"/>
        <value value="881234"/>
</identifier>

<status value="active"/>

<created value="2014-08-16"/>

<request>
        <reference value="http://www.BenefitsInc.com/fhir/EligibilityRequest/225476332402"/>
</request>

<outcome>
        <coding>
                <system value="http://hl7.org/fhir/remittance-outcome"/>
                <code value="complete"/>
        </coding>
</outcome>

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

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

<inforce value="true"/>

<insurance>
        <benefitBalance>
                <category>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-category"/>
                                <code value="medical"/>
                        </coding>
                </category>

                <subCategory>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                <code value="30"/>
                                <display value="Health Benefit Plan Coverage"/>
                        </coding>
                </subCategory>

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

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

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

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

                        <allowedMoney>
                                <value value="500000"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="SAR"/> 
                        </allowedMoney>
                </financial>

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

                        <allowedMoney>
                                <value value="100"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="SAR"/> 
                        </allowedMoney>
                </financial>

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

                        <allowedUnsignedInt value="20"/>
                </financial>
        </benefitBalance>

        <benefitBalance>
                <category>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-category"/>
                                <code value="medical"/>
                        </coding>
                </category>

                <subCategory>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                <code value="69"/>
                                <display value="Maternity"/>
                        </coding>
                </subCategory>

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

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

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

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

                        <allowedMoney>
                                <value value="15000"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="SAR"/> 
                        </allowedMoney>
                </financial>

        </benefitBalance>
        <benefitBalance>
                <category>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-category"/>
                                <code value="oral"/>
                        </coding>
                </category>

                <subCategory>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                <code value="F3"/>
                                <display value="Dental Coverage"/>
                        </coding>
                </subCategory>

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

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

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

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

                        <allowedMoney>
                                <value value="2000"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="SAR"/> 
                        </allowedMoney>
                </financial>

        </benefitBalance>
        <benefitBalance>
                <category>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-category"/>
                                <code value="vision"/>
                        </coding>
                </category>

                <subCategory>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                <code value="F6"/>
                                <display value="Vision Coverage"/>
                        </coding>
                </subCategory>

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

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

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

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

                        <allowedMoney>
                                <value value="400"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="SAR"/> 
                        </allowedMoney>
                </financial>

        </benefitBalance>
        <benefitBalance>
                <category>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-category"/>
                                <code value="vision"/>
                        </coding>
                </category>

                <subCategory>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                <code value="49"/>
                                <display value="Hospital Room and Board"/>
                        </coding>
                </subCategory>

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

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

                <term>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-term"/>
                                <code value="day"/>
                        </coding>
                </term>

                <financial>
                        <type>
                                <coding>
                                        <code value="room"/>
                                </coding>
                        </type>

                        <allowedString value="shared"/>
                </financial>
                <financial>
                        <type>
                                <coding>
                                        <code value="benefit"/>
                                </coding>
                        </type>

                        <allowedMoney>
                                <value value="600"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="SAR"/> 
                        </allowedMoney>
                </financial>

        </benefitBalance>
</insurance>

</EligibilityResponse>