Da Vinci - Payer Coverage Decision Exchange (PCDE)
1.0.0 - STU 1
Da Vinci - Payer Coverage Decision Exchange (PCDE)
1.0.0 - STU 1
This page is part of the Da Vinci Payer Coverage Decision Exchange (PCDE) FHIR IG (v1.0.0: STU 1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
<Bundle xmlns="http://hl7.org/fhir">
<id value="pcde-document"/>
<meta>
<lastUpdated value="2019-07-21T11:01:00+05:00"/>
</meta>
<identifier>
<system value="http://originalinsuranceinc.com/documentIDs"/>
<value value="A12345"/>
</identifier>
<type value="document"/>
<timestamp value="2019-07-21T11:01:00+05:00"/>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/Composition/1"/>
<resource>
<Composition>
<id value="1"/>
<meta>
<!-- There's no expectation that most instances would declare a profile. It's done here to help with publishing validation -->
<profile
value="http://hl7.org/fhir/us/davinci-pcde/StructureDefinition/profile-composition"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>status</b>: final</p><p><b>type</b>: <span title="Codes: {http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes pcde}">Coverage Transition Document</span></p><p><b>date</b>: Jul 21, 2019 4:09:00 PM</p><p><b>author</b>: <a href="#Practitioner_1">See above (Practitioner/1)</a></p><p><b>title</b>: Coverage Decision Exchange Document (Joe Smith, 2019-07-21)</p><h3>Events</h3><table class="grid"><tr><td>-</td><td><b>Detail</b></td></tr><tr><td>*</td><td><a href="#Coverage_1">See above (Coverage/1)</a></td></tr></table></div>
</text>
<status value="final"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes"/>
<code value="pcde"/>
</coding>
</type>
<subject>
<reference value="Patient/1"/>
</subject>
<date value="2019-07-21T23:09:00+07:00"/>
<author>
<reference value="Practitioner/1"/>
</author>
<title
value="Coverage Decision Exchange Document (Joe Smith, 2019-07-21)"/>
<event>
<detail>
<reference value="Coverage/1"/>
</detail>
</event>
<section>
<title value="Active Treatments"/>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes"/>
<code value="activeTreatment"/>
</coding>
</code>
<section>
<title value="Consulation re: MCI"/>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes"/>
<code value="treatment"/>
</coding>
</code>
<entry>
<reference value="CarePlan/1"/>
</entry>
</section>
<section>
<title value="Prior coverage"/>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes"/>
<code value="priorCoverage"/>
</coding>
</code>
<entry>
<reference value="Claim/1"/>
</entry>
<entry>
<reference value="ClaimResponse/1"/>
</entry>
</section>
<section>
<title value="Supporting information"/>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes"/>
<code value="supportingInfo"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
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.
Dr. Gardener had referred Joe to Dr. Susan Watson, a cardiologist for a consultation.
During the consultation examination, Dr. Watson determined that Joe’s diagnosis requires hospitalization and a surgical procedure, a triple bypass venous graft.
The operation and recovery was at Montgomery Hospital.
</div>
</text>
<entry>
<reference value="DocumentReference/1"/>
</entry>
</section>
</section>
</Composition>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/Patient/1"/>
<resource>
<Patient>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 444222222</p><p><b>name</b>: JOE SMITH </p><p><b>gender</b>: male</p></div>
</text>
<identifier>
<system
value="http://originalinsuranceinc.com/fhir/NamingSystem/client-ids"/>
<value value="444222222"/>
</identifier>
<name>
<family value="SMITH"/>
<given value="JOE"/>
</name>
<gender value="male"/>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/Coverage/1"/>
<resource>
<Coverage>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>status</b>: active</p><p><b>subscriberId</b>: 12345678</p><p><b>beneficiary</b>: <a href="#Patient_1">See above (Patient/1)</a></p><p><b>payor</b>: <a href="#Organization_1">See above (Organization/1)</a></p></div>
</text>
<status value="active"/>
<subscriberId value="12345678"/>
<beneficiary>
<reference value="Patient/1"/>
</beneficiary>
<payor>
<reference value="Organization/1"/>
</payor>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/Organization/1"/>
<resource>
<Organization>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 789312</p><p><b>active</b>: true</p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>
</text>
<identifier>
<system value="http://originalinsuranceinc.com/fhir/NamingSystem/ETIN"/>
<value value="789312"/>
</identifier>
<active value="true"/>
<name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/CarePlan/1"/>
<resource>
<CarePlan>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>instantiatesUri</b>: <a href="http://originalinsuranceinc.com/consultReviewURI">http://originalinsuranceinc.com/consultReviewURI</a></p><p><b>status</b>: active</p><p><b>intent</b>: plan</p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/core/CodeSystem/careplan-category assess-plan}">Assessment and Plan of Treatment</span></p><p><b>subject</b>: <a href="#Patient_1">See above (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><span title="Codes: {http://example.org/SERVICE_TYPE_CODE 3}">Consultation</span></td><td><a href="#Condition_1">See above (Condition/1)</a></td><td>in-progress</td></tr></table></blockquote></div>
</text>
<instantiatesUri
value="http://originalinsuranceinc.com/consultReviewURI"/>
<status value="active"/>
<intent value="plan"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/core/CodeSystem/careplan-category"/>
<code value="assess-plan"/>
</coding>
</category>
<subject>
<reference value="Patient/1"/>
</subject>
<activity>
<detail>
<code>
<coding>
<system value="http://example.org/SERVICE_TYPE_CODE"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</code>
<reasonReference>
<reference value="Condition/1"/>
</reasonReference>
<status value="in-progress"/>
</detail>
</activity>
</CarePlan>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/Claim/1"/>
<resource>
<Claim>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 111099</p><p><b>status</b>: active</p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href="#Patient_1">See above (Patient/1)</a></p><p><b>created</b>: 2019-07-20</p><p><b>insurer</b>: <a href="#Organization_1">See above (Organization/1)</a></p><p><b>provider</b>: <a href="http://example.org/fhir/Organization/provider">http://example.org/fhir/Organization/provider</a></p><p><b>priority</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><h3>CareTeams</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><a href="http://example.org/fhir/Organization/provider">http://example.org/fhir/Organization/provider</a></td></tr></table><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><span title="Codes: {http://hl7.org/fhir/sid/icd-10-cm G89.4}">Chronic pain syndrome</span></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">See above (Coverage/1)</a></td></tr></table><h3>Items</h3><table class="grid"><tr><td>-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>CareTeamSequence</b></td><td><b>DiagnosisSequence</b></td><td><b>ProductOrService</b></td><td><b>Location[x]</b></td></tr><tr><td>*</td><td>, , </td><td>1</td><td>1</td><td>1</td><td><span title="Codes: {http://codesystem.x12.org/005010/1365 3}">Consultation</span></td><td><span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">11</span></td></tr></table></div>
</text>
<identifier>
<system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
<value value="111099"/>
<assigner>
<identifier>
<system value="http://example.org/USER_ASSIGNED"/>
<value value="9012345678"/>
</identifier>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
</coding>
</type>
<use value="preauthorization"/>
<patient>
<reference value="Patient/1"/>
</patient>
<created value="2019-07-20"/>
<insurer>
<reference value="Organization/1"/>
</insurer>
<provider>
<reference value="http://example.org/fhir/Organization/provider"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
<display value="Normal"/>
</coding>
</priority>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="http://example.org/fhir/Organization/provider"/>
</provider>
</careTeam>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="G89.4"/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>
<reference value="Coverage/1"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="http://codesystem.x12.org/005010/1525"/>
<code value="SC"/>
<display value="Specialty Care Review"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
<valueCodeableConcept>
<coding>
<system value="http://codesystem.x12.org/005010/1322"/>
<code value="I"/>
<display value="Initial"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService">
<valueReference>
<reference value="ServiceRequest/1"/>
</valueReference>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<productOrService>
<coding>
<system value="http://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
</coding>
</locationCodeableConcept>
</item>
</Claim>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/ClaimResponse/1"/>
<resource>
<ClaimResponse>
<id value="1"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 111099</p><p><b>status</b>: active</p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href="#Patient_1">See above (Patient/1)</a></p><p><b>created</b>: 2019-07-20</p><p><b>insurer</b>: <a href="#Organization_1">See above (Organization/1)</a></p><p><b>requestor</b>: <a href="http://example.org/fhir/Organization/provider">http://example.org/fhir/Organization/provider</a></p><p><b>outcome</b>: complete</p><blockquote><p><b>item</b></p><blockquote><p><b>ReviewAction</b></p><h3>Urls</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>value</b>: AUTH0001</p><h3>Urls</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>value</b>: <span title="Codes: {http://codesystem.x12.org/005010/306 A1}">Certified in total</span></p></blockquote><p><b>AuthorizedDate</b>: 2005-05-02 --> 2005-06-02</p><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class="grid"><tr><td>-</td><td><b>Category</b></td></tr><tr><td>*</td><td><span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></td></tr></table></blockquote></div>
</text>
<identifier>
<system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
<value value="111099"/>
<assigner>
<identifier>
<system value="http://example.org/USER_ASSIGNED"/>
<value value="9012345678"/>
</identifier>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
</coding>
</type>
<use value="preauthorization"/>
<patient>
<reference value="Patient/1"/>
</patient>
<created value="2019-07-20"/>
<insurer>
<reference value="Organization/1"/>
</insurer>
<requestor>
<reference value="http://example.org/fhir/Organization/provider"/>
</requestor>
<outcome value="complete"/>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
<extension url="number">
<valueString value="AUTH0001"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode">
<valueCodeableConcept>
<coding>
<system value="http://codesystem.x12.org/005010/306"/>
<code value="A1"/>
<display value="Certified in total"/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate">
<valuePeriod>
<start value="2005-05-02"/>
<end value="2005-06-02"/>
</valuePeriod>
</extension>
<itemSequence value="1"/>
<adjudication>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
</category>
</adjudication>
</item>
</ClaimResponse>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/Practitioner/1"/>
<resource>
<Practitioner>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 8189991234</p><p><b>name</b>: JAMES GARDENER </p></div>
</text>
<identifier>
<system value="http://originalinsuranceinc.com/fhir/NamingSystem/ETIN"/>
<value value="8189991234"/>
</identifier>
<name>
<family value="GARDENER"/>
<given value="JAMES"/>
</name>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/ServiceRequest/1"/>
<resource>
<ServiceRequest>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>status</b>: active</p><p><b>intent</b>: order</p><p><b>code</b>: <span title="Codes: {http://codesystem.x12.org/005010/1365 3}">Consultation</span></p><p><b>quantity</b>: 1 VS</p><p><b>subject</b>: <a href="#Patient_1">See above (Patient/1)</a></p><p><b>performer</b>: <a href="#PractitionerRole_1">See above (PractitionerRole/1)</a></p></div>
</text>
<status value="active"/>
<intent value="order"/>
<code>
<coding>
<system value="http://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</code>
<quantityQuantity>
<value value="1"/>
<unit value="VS"/>
</quantityQuantity>
<subject>
<reference value="Patient/1"/>
</subject>
<performer>
<reference value="PractitionerRole/1"/>
</performer>
</ServiceRequest>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/Condition/1"/>
<resource>
<Condition>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/condition-category encounter-diagnosis}">Encounter Diagnosis</span></p><p><b>code</b>: <span title="Codes: {http://hl7.org/fhir/sid/icd-9-cm 410.90}">Acute myocardial infarction of unspecified site, episode of care unspecified</span></p><p><b>subject</b>: <a href="#Patient_1">See above (Patient/1)</a></p><p><b>recordedDate</b>: 2005-04-30</p></div>
</text>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-category"/>
<code value="encounter-diagnosis"/>
</coding>
</category>
<code>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm"/>
<code value="410.90"/>
</coding>
</code>
<subject>
<reference value="Patient/1"/>
</subject>
<recordedDate value="2005-04-30"/>
</Condition>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/PractitionerRole/1"/>
<resource>
<PractitionerRole>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>practitioner</b>: <a href="#Practitioner_2">See above (Practitioner/2)</a></p><p><b>code</b>: <span title="Codes: {http://example.org/fhir/NamingSystem/ENTITY_IDENTIFIER_CODE 1P}">Provider</span></p></div>
</text>
<practitioner>
<reference value="Practitioner/2"/>
</practitioner>
<code>
<coding>
<system
value="http://example.org/fhir/NamingSystem/ENTITY_IDENTIFIER_CODE"/>
<code value="1P"/>
<display value="Provider"/>
</coding>
</code>
</PractitionerRole>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/Practitioner/2"/>
<resource>
<Practitioner>
<id value="2"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 987654321</p><p><b>name</b>: SUSAN WATSON </p><p><b>telecom</b>: ph: 4029993456</p></div>
</text>
<identifier>
<system
value="http://originalinsuranceinc.com/fhir/NamingSystem/practitioner-id"/>
<value value="987654321"/>
</identifier>
<name>
<family value="WATSON"/>
<given value="SUSAN"/>
</name>
<telecom>
<system value="phone"/>
<value value="4029993456"/>
</telecom>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl value="http://originalinsuranceinc.com/fhir/DocumentReference/1"/>
<resource>
<DocumentReference>
<id value="1"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>status</b>: current</p><p><b>docStatus</b>: final</p><p><b>type</b>: <span title="Codes: {http://loinc.org 18842-5}">Discharge summary</span></p><p><b>subject</b>: <a href="#Patient_1">See above (Patient/1)</a></p><p><b>author</b>: <a href="#Practitioner_1">See above (Practitioner/1)</a></p><blockquote><p><b>content</b></p><h3>Attachments</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></div>
</text>
<status value="current"/>
<docStatus value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="18842-5"/>
</coding>
</type>
<subject>
<reference value="Patient/1"/>
</subject>
<author>
<reference value="Practitioner/1"/>
</author>
<content>
<attachment>
<url
value="http://originalinsuranceinc.com/fhir/Binary/DischargeSummaryDocument"/>
</attachment>
</content>
</DocumentReference>
</resource>
</entry>
</Bundle>
IG © 2019+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-pcde#1.0.0 based on FHIR 4.0.1. Generated 2020-12-23
Links: Table of Contents |
QA Report
| Version History |
Search |
|
Propose a change