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

<id value="E2502"/>

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

<contained>
        <Patient>
                <id value="patient-1"/>
                <name>
                        <use value="official"/>
                        <family value="Donald"/>
                        <given value="Duck"/>
                </name>
                <gender value="male"/>
                <birthDate value="1986-05-17"/>
                <address>
                        <use value="home"/>
                        <line value="1234 Main Street"/>
                        <city value="Vancouver"/>
                        <postalCode value="V2H1Y3"/>
                        <country value="CAD"/>
                </address>
        </Patient>
</contained>

<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://hl7.org/fhir/v3/ActCode"/>
                                <code value="EHCPOL"/>
                        </coding>
                </type>

                <subscriber>
                        <reference value="#patient-1"/>
                </subscriber>

                <beneficiary>
                        <reference value="#patient-1"/>
                </beneficiary>

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

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

                <grouping>
                        <plan value="CBI35"/>
                        <planDisplay value="Corporate Baker&#39;s Inc. Plan#35"/>
                        <subPlan value="123"/>
                        <subPlanDisplay value="Trainee Part-time Benefits"/>
                </grouping> 

                <dependent value="1"/>
                <sequence value="1"/>
        </Coverage>
</contained>

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

<status value="active"/>

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

<requestProvider>
        <identifier>
                <system value="http://national.org/provider"/>
                <value value="PR9876"/>
        </identifier>  
</requestProvider>

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

<request>
        <reference value="http://www.BenefitsInc.com/fhir/EligibilityRequest/225476332405"/>
</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>
        <coverage>
                <reference value="#coverage-1"/>
        </coverage>
        <contract>
                <reference value="http://www.BenefitsInc.com/fhir/Contract/NBU22547"/>
        </contract>
        <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="USD"/> 
                        </allowedMoney>

                        <usedMoney>
                                <value value="3748.00"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="USD"/> 
                        </usedMoney>

                </financial>

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

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

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

        </benefitBalance>
</insurance>

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

</EligibilityResponse>