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

PCDE Bundle example - XML Representation

(back to narrative)

Raw xml 


<Bundle xmlns="http://hl7.org/fhir">
  <id value="pcde-example"/>
  <meta>
    <lastUpdated value="2019-07-21T11:01:00+05:00"/>
  </meta>
  <identifier>
    <system value="http://example.org/documentIDs"/>
    <value value="A12345"/>
  </identifier>
  <type value="document"/>
  <timestamp value="2019-07-21T11:01:00+05:00"/>
  <entry>
    <fullUrl value="http://example.org/fhir/Composition/1"/>
    <resource>
      <Composition>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="final"/>
        <type>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEDocumentCode"/>
            <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="Example PCDE Document for Diabetes patient"/>
        <event>
          <detail>
            <reference value="Coverage/1"/>
          </detail>
        </event>
        <section>
          <code>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDESectionCode"/>
              <code value="activeTreatment"/>
            </coding>
          </code>
          <section>
            <code>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDESectionCode"/>
                <code value="treatment"/>
              </coding>
            </code>
            <entry>
              <reference value="CarePlan/1"/>
            </entry>
          </section>
          <section>
            <code>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDESectionCode"/>
                <code value="priorCoverage"/>
              </coding>
            </code>
            <entry>
              <reference value="Claim/1"/>
            </entry>
            <entry>
              <reference value="ClaimResponse/1"/>
            </entry>
          </section>
          <section>
            <code>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDESectionCode"/>
                <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://example.org/fhir/Patient/1"/>
    <resource>
      <Patient>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <system value="http://example.org/MIN"/>
          <value value="12345678901"/>
        </identifier>
        <name>
          <family value="SMITH"/>
          <given value="JOE"/>
        </name>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Coverage/1"/>
    <resource>
      <Coverage>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="active"/>
        <beneficiary>
          <reference value="Patient/1"/>
        </beneficiary>
        <payor>
          <reference value="Organization/1"/>
        </payor>
      </Coverage>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Organization/1"/>
    <resource>
      <Organization>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <system value="http://example.org/ETIN"/>
          <value value="789312"/>
        </identifier>
        <name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/CarePlan/1"/>
    <resource>
      <CarePlan>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <instantiatesUri value="http://example.org/consultReviewURI"/>
        <status value="active"/>
        <intent value="order"/>
        <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://example.org/fhir/Claim/1"/>
    <resource>
      <Claim>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
          <value value="111099"/>
        </identifier>
        <status value="active"/>
        <type>
          <coding>
            <system value="http://example.org/UM_REQUEST_CATEGORY_CODE"/>
            <code value="SC"/>
            <display value="Specialty Care Review"/>
          </coding>
        </type>
        <use value="preauthorization">
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
            <valueCode value="I"/>
          </extension>
        </use>
        <patient>
          <reference value="Patient/1"/>
        </patient>
        <created value="2019-07-20"/>
        <insurer>
          <reference value="Organization/1"/>
        </insurer>
        <provider>
          <reference value="Practitioner/1"/>
        </provider>
        <priority>
          <coding>
            <system
                    value="http://terminology/hl7.org/CodeSystem/processpriority"/>
            <code value="normal"/>
            <display value="Normal"/>
          </coding>
        </priority>
        <prescription>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService">
            <valueReference>
              <reference value="ServiceRequest/1"/>
            </valueReference>
          </extension>
          <display value="see requested service extension"/>
        </prescription>
        <diagnosis>
          <sequence value="1"/>
          <diagnosisReference>
            <reference value="Condition/1"/>
          </diagnosisReference>
        </diagnosis>
        <insurance>
          <sequence value="1"/>
          <focal value="true"/>
          <coverage>
            <reference value="Coverage/1"/>
          </coverage>
        </insurance>
      </Claim>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/ClaimResponse/1"/>
    <resource>
      <ClaimResponse>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
          <valueCode value="A1"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedEventDate">
          <valuePeriod>
            <start value="2005-05-02"/>
            <end value="2005-06-02"/>
          </valuePeriod>
        </extension>
        <identifier>
          <system value="http://example.org/REVIEW_IDENTIFICATION_NUMBER"/>
          <value value="AUTH0001"/>
        </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="Practitioner/1"/>
        </requestor>
        <outcome value="complete"/>
      </ClaimResponse>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Practitioner/1"/>
    <resource>
      <Practitioner>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <system value="http://example.org/ETIN"/>
          <value value="8189991234"/>
        </identifier>
        <name>
          <family value="GARDENER"/>
          <given value="JAMES"/>
        </name>
      </Practitioner>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/ServiceRequest/1"/>
    <resource>
      <ServiceRequest>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="active"/>
        <intent value="plan"/>
        <code>
          <coding>
            <system value="http://example.org/SERVICE_TYPE_CODE"/>
            <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://example.org/fhir/Condition/1"/>
    <resource>
      <Condition>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <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://example.org/fhir/PractitionerRole/1"/>
    <resource>
      <PractitionerRole>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <practitioner>
          <reference value="Practitioner/2"/>
        </practitioner>
        <code>
          <coding>
            <system value="http://example.org/ENTITY_IDENTIFIER_CODE"/>
            <code value="1P"/>
            <display value="Provider"/>
          </coding>
        </code>
      </PractitionerRole>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Practitioner/2"/>
    <resource>
      <Practitioner>
        <id value="2"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <system value="http://example.org/SSN"/>
          <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://example.org/fhir/DocumentReference/1"/>
    <resource>
      <DocumentReference>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </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://example.org/DischargeSummaryDocument"/>
          </attachment>
        </content>
      </DocumentReference>
    </resource>
  </entry>
</Bundle>