This scenario walks a patient from successful plan selection and enrollment through routine use of coverage during a visit. Eligibility checks return affirmative answers, and the resulting claim moves predictably toward adjudication without denials or complex exceptions.
from zato_fhir.test.r4.v1 import Scenarios, TestData
for enrollment in Scenarios.insurance_enrollment:
for name in enrollment.patient.name:
print(name.text)
print(enrollment.organization.name)
for enc in enrollment.encounters:
print(enc.status)
print(enrollment.coverage.status)
print(enrollment.insurance_plan.status)
print(enrollment.enrollment_request.status)
print(enrollment.enrollment_response.status)
print(enrollment.eligibility_request.status)
print(enrollment.eligibility_response.status)
print(enrollment.claim.status)
print(enrollment.claim_response.status)
print(enrollment.explanation_of_benefit.status)
print(enrollment.payment_notice.status)
print(enrollment.payment_reconciliation.status)
print(enrollment.invoice.status)
print(enrollment.charge_item.status)
print(enrollment.charge_item_definition.status)
print(enrollment.account.status)
print(enrollment.contract.status)
for cov in TestData.Coverage:
print(cov.status)This scenario walks a patient from successful plan selection and enrollment through routine use of coverage during a visit. Eligibility checks return affirmative answers, and the resulting claim moves predictably toward adjudication without denials or complex exceptions.
Explanations of benefit, payment notices, and reconciliation resources show funds flowing as expected, while charge items, contracts, and accounts tie operational billing back to the clinical encounter. The story stays upbeat: coverage is active, services are allowed, and balances resolve in good order.
21 resources per instance, 210 total across 10 instances.
| FHIR resource type | Role in this scenario |
|---|---|
Patient | Insured individual |
Organization | Payer, provider, or affiliated legal entity |
Encounter | Covered service encounter |
Coverage | Active member coverage |
InsurancePlan | Marketed plan characteristics |
EnrollmentRequest | Application into a plan |
EnrollmentResponse | Accepted enrollment decision |
CoverageEligibilityRequest | Real-time or scheduled eligibility inquiry |
CoverageEligibilityResponse | Affirmative eligibility outcome |
Claim | Institutional or professional claim submission |
ClaimResponse | Adjudication result |
ExplanationOfBenefit | Member-facing payment explanation |
PaymentNotice | Notice of payment issuance |
PaymentReconciliation | Reconciliation of payments to claims |
Invoice | Bill aligned to services |
ChargeItem | Line-level charges |
ChargeItemDefinition | Rule or catalog behind charges |
Account | Financial account holding balances |
Contract | Agreement underpinning coverage or rates |
FHIR resources per instance | 21 |
Total resources (10 instances) | 210 |
Distinct resource types | 19 |
Scenario identifier | `Scenarios.insurance_enrollment` |
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