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. For a full list of available versions, see the Directory of published versions

Example Binary: Payers Section Example

This content is an example of the Payers Section Logical Model and is not a FHIR Resource

    
<section xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:sdtc="urn:hl7-org:sdtc">
  <templateId root="2.16.840.1.113883.10.20.22.2.18" extension="2015-08-01" />
  <!--  ******** Payers section template  ******** -->
  <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payers" />
  <title>Insurance Providers</title>
  <text>
        . . . 
    </text>
  <entry typeCode="DRIV">
		<act classCode="ACT" moodCode="EVN" xmlns="urn:hl7-org:v3">
		  <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"/>
			  <text>
				<reference value="#policyactivity" />
			  </text>
		      <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"/>
				<time xsi:type="IVL_TS">
					<low value="20130905"/>
					<high value="20150905"/>
				</time>
		        <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>
  </entry>
</section>