Da Vinci - Payer Coverage Decision Exchange
0.1.0 - STU Ballot
Da Vinci - Payer Coverage Decision Exchange
0.1.0 - STU Ballot
This page is part of the Da Vinci Payer Coverage Decision Exchange (PCDE) FHIR IG (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
{
"resourceType" : "Bundle",
"id" : "pcde-example",
"meta" : {
"lastUpdated" : "2019-07-21T11:01:00+05:00"
},
"identifier" : {
"system" : "http://example.org/documentIDs",
"value" : "A12345"
},
"type" : "document",
"timestamp" : "2019-07-21T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/Composition/1",
"resource" : {
"resourceType" : "Composition",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>status</b>: final</p><p><b>type</b>: Coverage Transition Document <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEDocumentCode code 'pcde' = 'Coverage Transition Document)</span></p><p><b>date</b>: Jul 21, 2019 12:09:00 PM</p><p><b>author</b>: <a href=\"Practitioner/1\">Practitioner/1</a></p><p><b>title</b>: Example PCDE Document for Diabetes patient</p><h3>Events</h3><table class=\"grid\"><tr><td>-</td><td><b>Detail</b></td></tr><tr><td>*</td><td><a href=\"Coverage/1\">Coverage/1</a></td></tr></table></div>"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEDocumentCode",
"code" : "pcde"
}
]
},
"subject" : {
"reference" : "Patient/1"
},
"date" : "2019-07-21T23:09:00+07:00",
"author" : [
{
"reference" : "Practitioner/1"
}
],
"title" : "Example PCDE Document for Diabetes patient",
"event" : [
{
"detail" : [
{
"reference" : "Coverage/1"
}
]
}
],
"section" : [
{
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDESectionCode",
"code" : "activeTreatment"
}
]
},
"section" : [
{
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDESectionCode",
"code" : "treatment"
}
]
},
"entry" : [
{
"reference" : "CarePlan/1"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDESectionCode",
"code" : "priorCoverage"
}
]
},
"entry" : [
{
"reference" : "Claim/1"
},
{
"reference" : "ClaimResponse/1"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDESectionCode",
"code" : "supportingInfo"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n Joe Smith is a subscriber to Maryland Capital Insurance Company. During a regular physical, Dr. James Gardener, Joe’s primary care physician, diagnosed a potential heart problem, acute myocardial infarction; unspecified site. \n Dr. Gardener had referred Joe to Dr. Susan Watson, a cardiologist for a consultation.\n During the consultation examination, Dr. Watson determined that Joe’s diagnosis requires hospitalization and a surgical procedure, a triple bypass venous graft. \n The operation and recovery was at Montgomery Hospital.\n </div>"
},
"entry" : [
{
"reference" : "DocumentReference/1"
}
]
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Patient/1",
"resource" : {
"resourceType" : "Patient",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: 12345678901</p><p><b>name</b>: JOE SMITH </p></div>"
},
"identifier" : [
{
"system" : "http://example.org/MIN",
"value" : "12345678901"
}
],
"name" : [
{
"family" : "SMITH",
"given" : [
"JOE"
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Coverage/1",
"resource" : {
"resourceType" : "Coverage",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>payor</b>: <a href=\"Organization/1\">Organization/1</a></p></div>"
},
"status" : "active",
"beneficiary" : {
"reference" : "Patient/1"
},
"payor" : [
{
"reference" : "Organization/1"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/1",
"resource" : {
"resourceType" : "Organization",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: 789312</p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>"
},
"identifier" : [
{
"system" : "http://example.org/ETIN",
"value" : "789312"
}
],
"name" : "MARYLAND CAPITAL INSURANCE COMPANY"
}
},
{
"fullUrl" : "http://example.org/fhir/CarePlan/1",
"resource" : {
"resourceType" : "CarePlan",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>instantiatesUri</b>: <a href=\"http://example.org/consultReviewURI\">http://example.org/consultReviewURI</a></p><p><b>status</b>: active</p><p><b>intent</b>: order</p><p><b>category</b>: Assessment and Plan of Treatment <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/us/core/CodeSystem/careplan-category code 'assess-plan' = 'Assessment and Plan of Treatment)</span></p><p><b>subject</b>: <a href=\"Patient/1\">Patient/1</a></p><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td>-</td><td><b>Code</b></td><td><b>ReasonReference</b></td><td><b>Status</b></td></tr><tr><td>*</td><td>Consultation <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/SERVICE_TYPE_CODE code '3' = '3', given as 'Consultation'})</span></td><td><a href=\"Condition/1\">Condition/1</a></td><td>in-progress</td></tr></table></blockquote></div>"
},
"instantiatesUri" : [
"http://example.org/consultReviewURI"
],
"status" : "active",
"intent" : "order",
"category" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/core/CodeSystem/careplan-category",
"code" : "assess-plan"
}
]
}
],
"subject" : {
"reference" : "Patient/1"
},
"activity" : [
{
"detail" : {
"code" : {
"coding" : [
{
"system" : "http://example.org/SERVICE_TYPE_CODE",
"code" : "3",
"display" : "Consultation"
}
]
},
"reasonReference" : [
{
"reference" : "Condition/1"
}
],
"status" : "in-progress"
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Claim/1",
"resource" : {
"resourceType" : "Claim",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: 111099</p><p><b>status</b>: active</p><p><b>type</b>: Specialty Care Review <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/UM_REQUEST_CATEGORY_CODE code 'SC' = 'SC', given as 'Specialty Care Review'})</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>created</b>: Jul 20, 2019 12:00:00 AM</p><p><b>insurer</b>: <a href=\"Organization/1\">Organization/1</a></p><p><b>provider</b>: <a href=\"Practitioner/1\">Practitioner/1</a></p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology/hl7.org/CodeSystem/processpriority code 'normal' = 'normal', given as 'Normal'})</span></p><p><b>prescription</b>: see requested service extension</p><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td>*</td><td>1</td><td><a href=\"Condition/1\">Condition/1</a></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><a href=\"Coverage/1\">Coverage/1</a></td></tr></table></div>"
},
"identifier" : [
{
"system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value" : "111099"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://example.org/UM_REQUEST_CATEGORY_CODE",
"code" : "SC",
"display" : "Specialty Care Review"
}
]
},
"use" : "preauthorization",
"_use" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
"valueCode" : "I"
}
]
},
"patient" : {
"reference" : "Patient/1"
},
"created" : "2019-07-20",
"insurer" : {
"reference" : "Organization/1"
},
"provider" : {
"reference" : "Practitioner/1"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology/hl7.org/CodeSystem/processpriority",
"code" : "normal",
"display" : "Normal"
}
]
},
"prescription" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
"valueReference" : {
"reference" : "ServiceRequest/1"
}
}
],
"display" : "see requested service extension"
},
"diagnosis" : [
{
"sequence" : 1,
"diagnosisReference" : {
"reference" : "Condition/1"
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/1"
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/ClaimResponse/1",
"resource" : {
"resourceType" : "ClaimResponse",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: AUTH0001</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/claim-type code 'professional' = 'Professional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>created</b>: Jul 20, 2019 12:00:00 AM</p><p><b>insurer</b>: <a href=\"Organization/1\">Organization/1</a></p><p><b>requestor</b>: <a href=\"Practitioner/1\">Practitioner/1</a></p><p><b>outcome</b>: complete</p></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction",
"valueCode" : "A1"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedEventDate",
"valuePeriod" : {
"start" : "2005-05-02",
"end" : "2005-06-02"
}
}
],
"identifier" : [
{
"system" : "http://example.org/REVIEW_IDENTIFICATION_NUMBER",
"value" : "AUTH0001"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "professional"
}
]
},
"use" : "preauthorization",
"patient" : {
"reference" : "Patient/1"
},
"created" : "2019-07-20",
"insurer" : {
"reference" : "Organization/1"
},
"requestor" : {
"reference" : "Practitioner/1"
},
"outcome" : "complete"
}
},
{
"fullUrl" : "http://example.org/fhir/Practitioner/1",
"resource" : {
"resourceType" : "Practitioner",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: 8189991234</p><p><b>name</b>: JAMES GARDENER </p></div>"
},
"identifier" : [
{
"system" : "http://example.org/ETIN",
"value" : "8189991234"
}
],
"name" : [
{
"family" : "GARDENER",
"given" : [
"JAMES"
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/ServiceRequest/1",
"resource" : {
"resourceType" : "ServiceRequest",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>status</b>: active</p><p><b>intent</b>: plan</p><p><b>code</b>: Consultation <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/SERVICE_TYPE_CODE code '3' = '3', given as 'Consultation'})</span></p><p><b>quantity</b>: 1 VS</p><p><b>subject</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>performer</b>: <a href=\"PractitionerRole/1\">PractitionerRole/1</a></p></div>"
},
"status" : "active",
"intent" : "plan",
"code" : {
"coding" : [
{
"system" : "http://example.org/SERVICE_TYPE_CODE",
"code" : "3",
"display" : "Consultation"
}
]
},
"quantityQuantity" : {
"value" : 1,
"unit" : "VS"
},
"subject" : {
"reference" : "Patient/1"
},
"performer" : [
{
"reference" : "PractitionerRole/1"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Condition/1",
"resource" : {
"resourceType" : "Condition",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>code</b>: 410.90 <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/sid/icd-9-cm code '410.90' = '410.90)</span></p><p><b>subject</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>recordedDate</b>: Apr 30, 2005 12:00:00 AM</p></div>"
},
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-9-cm",
"code" : "410.90"
}
]
},
"subject" : {
"reference" : "Patient/1"
},
"recordedDate" : "2005-04-30"
}
},
{
"fullUrl" : "http://example.org/fhir/PractitionerRole/1",
"resource" : {
"resourceType" : "PractitionerRole",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>practitioner</b>: <a href=\"Practitioner/2\">Practitioner/2</a></p><p><b>code</b>: Provider <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/ENTITY_IDENTIFIER_CODE code '1P' = '1P', given as 'Provider'})</span></p></div>"
},
"practitioner" : {
"reference" : "Practitioner/2"
},
"code" : [
{
"coding" : [
{
"system" : "http://example.org/ENTITY_IDENTIFIER_CODE",
"code" : "1P",
"display" : "Provider"
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Practitioner/2",
"resource" : {
"resourceType" : "Practitioner",
"id" : "2",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 2</p><p><b>identifier</b>: 987654321</p><p><b>name</b>: SUSAN WATSON </p><p><b>telecom</b>: ph: 4029993456</p></div>"
},
"identifier" : [
{
"system" : "http://example.org/SSN",
"value" : "987654321"
}
],
"name" : [
{
"family" : "WATSON",
"given" : [
"SUSAN"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "4029993456"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/DocumentReference/1",
"resource" : {
"resourceType" : "DocumentReference",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>status</b>: current</p><p><b>docStatus</b>: final</p><p><b>type</b>: Discharge summary <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code '18842-5' = 'Discharge summary)</span></p><p><b>subject</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>author</b>: <a href=\"Practitioner/1\">Practitioner/1</a></p><h3>Contents</h3><table class=\"grid\"><tr><td>-</td><td><b>Attachment</b></td></tr><tr><td>*</td><td/></tr></table></div>"
},
"status" : "current",
"docStatus" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18842-5"
}
]
},
"subject" : {
"reference" : "Patient/1"
},
"author" : [
{
"reference" : "Practitioner/1"
}
],
"content" : [
{
"attachment" : {
"url" : "http://example.org/DischargeSummaryDocument"
}
}
]
}
}
]
}
IG © 2019+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-pcde#0.1.0 based on FHIR 4.0.0. Generated 2019-08-02
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