Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example Binary: Coverage Activity Example

This content is an example of the Coverage Activity Logical Model and is not a FHIR Resource

    
<act classCode="ACT" moodCode="EVN" xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
  <templateId root="2.16.840.1.113883.10.20.22.4.60" extension="2024-05-01" />
  <id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66" />
  <code code="52556-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment sources" />
  <text><reference value="#coverage"/></text>
  <statusCode code="completed" />
  <effectiveTime value="20230501"/>
  <entryRelationship typeCode="COMP">
    <sequenceNumber value="2" />
    <act classCode="ACT" moodCode="EVN">
      <!-- Policy Activity -->
      <templateId root="2.16.840.1.113883.10.20.22.4.61" extension="2024-05-01" />
      <id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66"/>
      <code code="1" codeSystem="2.16.840.1.113883.3.221.5" codeSystemName="SOP" displayName="MEDICARE"/>
      <statusCode code="completed"/>
      <performer typeCode="PRF">
        <templateId root="2.16.840.1.113883.10.20.22.4.87"/>
		    <assignedEntity>
		      <id root="2.16.840.1.113883.19" />
		      <code code="PAYOR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleCode" />
		      <addr use="WP">
		        <streetAddressLine>123 Insurance Road</streetAddressLine>
		        <city>Blue Bell</city>
		        <state>MA</state>
		        <postalCode>02368</postalCode>
		        <country>US</country>
		        <!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
		      </addr>
		      <telecom value="tel:+(555)555-1515" use="WP" />
		      <representedOrganization>
		        <name>Good Health Insurance</name>
		        <telecom value="tel:+(555)555-1515" use="WP" />
		        <addr use="WP">
		          <streetAddressLine>123 Insurance Road</streetAddressLine>
		          <city>Blue Bell</city>
		          <state>MA</state>
		          <postalCode>02368</postalCode>
		          <country>US</country>
		        </addr>
		      </representedOrganization>
		    </assignedEntity>
      </performer>
      <participant typeCode="COV">
        <!-- Coverage Target -->
        <templateId root="2.16.840.1.113883.10.20.22.4.89"/>
        <participantRole>
          <id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66"/>
          <code code="SELF" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="self"/>
		      <addr use="HP">
		        <streetAddressLine>17 Daws Rd.</streetAddressLine>
		        <city>Blue Bell</city>
		        <state>MA</state>
		        <postalCode>02368</postalCode>
		        <country>US</country>
		      </addr>
		      <playingEntity>
		        <name>
		          <!-- Name is needed if different than name on health plan. -->
		          <prefix>Mr.</prefix>
		          <given>Frank</given>
		          <given>A.</given>
		          <family>Everyman</family>
		        </name>
		        <sdtc:birthTime value="19620206" />
		      </playingEntity>
        </participantRole>
      </participant>
    </act>
  </entryRelationship>
</act>