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 
{
"resourceType" : "Bundle",
"id" : "pcde-document",
"meta" : {
"lastUpdated" : "2019-07-21T11:01:00+05:00"
},
"identifier" : {
"system" : "http://originalinsuranceinc.com/documentIDs",
"value" : "A12345"
},
"type" : "document",
"timestamp" : "2019-07-21T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/Composition/1",
"resource" : {
"resourceType" : "Composition",
"id" : "1",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pcde/StructureDefinition/profile-composition"
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes",
"code" : "pcde"
}
]
},
"subject" : {
"reference" : "Patient/1"
},
"date" : "2019-07-21T23:09:00+07:00",
"author" : [
{
"reference" : "Practitioner/1"
}
],
"title" : "Coverage Decision Exchange Document (Joe Smith, 2019-07-21)",
"event" : [
{
"detail" : [
{
"reference" : "Coverage/1"
}
]
}
],
"section" : [
{
"title" : "Active Treatments",
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes",
"code" : "activeTreatment"
}
]
},
"section" : [
{
"title" : "Consulation re: MCI",
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes",
"code" : "treatment"
}
]
},
"entry" : [
{
"reference" : "CarePlan/1"
}
]
},
{
"title" : "Prior coverage",
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes",
"code" : "priorCoverage"
}
]
},
"entry" : [
{
"reference" : "Claim/1"
},
{
"reference" : "ClaimResponse/1"
}
]
},
{
"title" : "Supporting information",
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pcde/CodeSystem/PCDEtempCodes",
"code" : "supportingInfo"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n 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. \n Dr. Gardener had referred Joe to Dr. Susan Watson, a cardiologist for a consultation.\n During the consultation examination, Dr. Watson determined that Joe’s diagnosis requires hospitalization and a surgical procedure, a triple bypass venous graft. \n The operation and recovery was at Montgomery Hospital.\n </div>"
},
"entry" : [
{
"reference" : "DocumentReference/1"
}
]
}
]
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/Patient/1",
"resource" : {
"resourceType" : "Patient",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"identifier" : [
{
"system" : "http://originalinsuranceinc.com/fhir/NamingSystem/client-ids",
"value" : "444222222"
}
],
"name" : [
{
"family" : "SMITH",
"given" : [
"JOE"
]
}
],
"gender" : "male"
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/Coverage/1",
"resource" : {
"resourceType" : "Coverage",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"status" : "active",
"subscriberId" : "12345678",
"beneficiary" : {
"reference" : "Patient/1"
},
"payor" : [
{
"reference" : "Organization/1"
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/Organization/1",
"resource" : {
"resourceType" : "Organization",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"identifier" : [
{
"system" : "http://originalinsuranceinc.com/fhir/NamingSystem/ETIN",
"value" : "789312"
}
],
"active" : true,
"name" : "MARYLAND CAPITAL INSURANCE COMPANY"
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/CarePlan/1",
"resource" : {
"resourceType" : "CarePlan",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"instantiatesUri" : [
"http://originalinsuranceinc.com/consultReviewURI"
],
"status" : "active",
"intent" : "plan",
"category" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/core/CodeSystem/careplan-category",
"code" : "assess-plan"
}
]
}
],
"subject" : {
"reference" : "Patient/1"
},
"activity" : [
{
"detail" : {
"code" : {
"coding" : [
{
"system" : "http://example.org/SERVICE_TYPE_CODE",
"code" : "3",
"display" : "Consultation"
}
]
},
"reasonReference" : [
{
"reference" : "Condition/1"
}
],
"status" : "in-progress"
}
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/Claim/1",
"resource" : {
"resourceType" : "Claim",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"identifier" : [
{
"system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value" : "111099",
"assigner" : {
"identifier" : {
"system" : "http://example.org/USER_ASSIGNED",
"value" : "9012345678"
}
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "professional"
}
]
},
"use" : "preauthorization",
"patient" : {
"reference" : "Patient/1"
},
"created" : "2019-07-20",
"insurer" : {
"reference" : "Organization/1"
},
"provider" : {
"reference" : "http://example.org/fhir/Organization/provider"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal",
"display" : "Normal"
}
]
},
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "http://example.org/fhir/Organization/provider"
}
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "G89.4"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/1"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://codesystem.x12.org/005010/1525",
"code" : "SC",
"display" : "Specialty Care Review"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://codesystem.x12.org/005010/1322",
"code" : "I",
"display" : "Initial"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
"valueReference" : {
"reference" : "ServiceRequest/1"
}
}
],
"sequence" : 1,
"careTeamSequence" : [
1
],
"diagnosisSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "11"
}
]
}
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/ClaimResponse/1",
"resource" : {
"resourceType" : "ClaimResponse",
"id" : "1",
"text" : {
"status" : "extensions",
"div" : "<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>"
},
"identifier" : [
{
"system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value" : "111099",
"assigner" : {
"identifier" : {
"system" : "http://example.org/USER_ASSIGNED",
"value" : "9012345678"
}
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "professional"
}
]
},
"use" : "preauthorization",
"patient" : {
"reference" : "Patient/1"
},
"created" : "2019-07-20",
"insurer" : {
"reference" : "Organization/1"
},
"requestor" : {
"reference" : "http://example.org/fhir/Organization/provider"
},
"outcome" : "complete",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction",
"extension" : [
{
"url" : "number",
"valueString" : "AUTH0001"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://codesystem.x12.org/005010/306",
"code" : "A1",
"display" : "Certified in total"
}
]
}
}
]
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate",
"valuePeriod" : {
"start" : "2005-05-02",
"end" : "2005-06-02"
}
}
],
"itemSequence" : 1,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
]
}
}
]
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/Practitioner/1",
"resource" : {
"resourceType" : "Practitioner",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"identifier" : [
{
"system" : "http://originalinsuranceinc.com/fhir/NamingSystem/ETIN",
"value" : "8189991234"
}
],
"name" : [
{
"family" : "GARDENER",
"given" : [
"JAMES"
]
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/ServiceRequest/1",
"resource" : {
"resourceType" : "ServiceRequest",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"status" : "active",
"intent" : "order",
"code" : {
"coding" : [
{
"system" : "http://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
},
"quantityQuantity" : {
"value" : 1,
"unit" : "VS"
},
"subject" : {
"reference" : "Patient/1"
},
"performer" : [
{
"reference" : "PractitionerRole/1"
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/Condition/1",
"resource" : {
"resourceType" : "Condition",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"category" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/condition-category",
"code" : "encounter-diagnosis"
}
]
}
],
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-9-cm",
"code" : "410.90"
}
]
},
"subject" : {
"reference" : "Patient/1"
},
"recordedDate" : "2005-04-30"
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/PractitionerRole/1",
"resource" : {
"resourceType" : "PractitionerRole",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"practitioner" : {
"reference" : "Practitioner/2"
},
"code" : [
{
"coding" : [
{
"system" : "http://example.org/fhir/NamingSystem/ENTITY_IDENTIFIER_CODE",
"code" : "1P",
"display" : "Provider"
}
]
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/Practitioner/2",
"resource" : {
"resourceType" : "Practitioner",
"id" : "2",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"identifier" : [
{
"system" : "http://originalinsuranceinc.com/fhir/NamingSystem/practitioner-id",
"value" : "987654321"
}
],
"name" : [
{
"family" : "WATSON",
"given" : [
"SUSAN"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "4029993456"
}
]
}
},
{
"fullUrl" : "http://originalinsuranceinc.com/fhir/DocumentReference/1",
"resource" : {
"resourceType" : "DocumentReference",
"id" : "1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"status" : "current",
"docStatus" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18842-5"
}
]
},
"subject" : {
"reference" : "Patient/1"
},
"author" : [
{
"reference" : "Practitioner/1"
}
],
"content" : [
{
"attachment" : {
"url" : "http://originalinsuranceinc.com/fhir/Binary/DischargeSummaryDocument"
}
}
]
}
}
]
}
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
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