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: Policy Activity Example

This content is an example of the Policy 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="2.16.840.1.113883.10.20.22.4.61" extension="2024-05-01" />
  <id root="3e676a50-7aac-11db-9fe1-0800200c9a66" />
  <code code="12" displayName="Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan" 
             codeSystemName="Insurance Type Code (x12N-1336)"
             codeSystem="2.16.840.1.113883.6.255.1336">
    <translation code="2" displayName="Medicare" 
                                    codeSystem="2.16.840.1.113883.3.221.5" codeSystemName="Source of Payment Typology (PHDSC)"></translation>
  </code>
  <statusCode code="completed" />
  <!-- Insurance company information -->
  <performer typeCode="PRF">
    <templateId root="2.16.840.1.113883.10.20.22.4.87" />
    <time>
      <low nullFlavor="UNK" />
      <high nullFlavor="UNK" />
    </time>
    <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>
  <!-- Guarantor information (the person responsible for the final bill) -->
  <performer typeCode="PRF">
    <templateId root="2.16.840.1.113883.10.20.22.4.88" />
    <time>
      <low nullFlavor="UNK" />
      <high nullFlavor="UNK" />
    </time>
    <assignedEntity>
      <id root="329fcdf0-7ab3-11db-9fe1-0800200c9a66" />
      <code code="GUAR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleCode" />
      <addr use="HP">
        <streetAddressLine>17 Daws Rd.</streetAddressLine>
        <city>Blue Bell</city>
        <state>MA</state>
        <postalCode>02368</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:+(781)555-1212" use="HP" />
      <assignedPerson>
        <name>
          <prefix>Mr.</prefix>
          <given>Adam</given>
          <given>Frankie</given>
          <family>Everyman</family>
        </name>
      </assignedPerson>
    </assignedEntity>
  </performer>
  <!-- Covered party -->
  <participant typeCode="COV">
    <templateId root="2.16.840.1.113883.10.20.22.4.89" />
    <time>
      <low nullFlavor="UNK" />
      <high nullFlavor="UNK" />
    </time>
    <participantRole classCode="PAT">
      <!-- Health plan ID for patient. -->
      <id root="1.1.1.1.1.1.1.1.14" extension="1138345" />
      <code code="FAMDEP" codeSystem="2.16.840.1.113883.5.111" />
      <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>
  <!-- Policy holder / Subscriber - not allowed if the COV participant's code is SELF -->
  <participant typeCode="HLD">
    <templateId root="2.16.840.1.113883.10.20.22.4.90" />
    <participantRole>
      <id extension="1138345" root="2.16.840.1.113883.19" />
      <addr use="HP">
        <streetAddressLine>17 Daws Rd.</streetAddressLine>
        <city>Blue Bell</city>
        <state>MA</state>
        <postalCode>02368</postalCode>
        <country>US</country>
      </addr>
    </participantRole>
  </participant>
  <!-- Coverange Plan
  <entryRelationship typeCode="REFR">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.19" />
             . . .
        
        
    </act>
  </entryRelationship> -->
</act>