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20140403 EmployerExample-Payer Section.xml
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20140403 EmployerExample-Payer Section.xml
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<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../../05%20Professional/90%20HL7/00%20Standard%20-%20C-CDA/20130409%20C-CDA%20R1dot1_2012JUL/Updated_CDA_Schema_Files_Extension_Support/CDA_Schema_Files/infrastructure/cda/CDA_SDTC.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<id root="1.3.6.1.4.1.12045.1.100.10" extension="5e83eff8-68de-4721-8d3c-94ef7f98e48c"/>
<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/>
<title>Intuit Healthcare Patient Form Data Extract</title>
<effectiveTime value="20140325162115.303-0400"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="899b721a-d202-4131-99cc-4f9b4c24e47b" extension="123"/> <!-- This id binds to the patient role -->
<addr><streetAddressLine>Buck Jones Road</streetAddressLine><city>Raleigh</city><state>NC</state><postalCode>12345</postalCode></addr>
<telecom value="tel:+1(123)456-7980"/>
<patient>
<name><family>DE7933_1</family><given>DE7933_1</given></name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19870101"/>
<ethnicGroupCode nullFlavor="UNK">
<originalText>Unknown</originalText>
</ethnicGroupCode>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20140325162115.305-0400"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="NA"/>
<id root="1.3.6.1.4.1.12045.1.30.1" extension="97c2f15c-e46d-48f6-bff9-1da69df968d1"/>
<addr><streetAddressLine>Buck Jones Road</streetAddressLine><city>Raleigh</city><state>NC</state><postalCode>12345</postalCode></addr>
<telecom value="tel:+1(123)456-7980"/>
<assignedPerson>
<name><family>DE7933_1</family><given>DE7933_1</given></name>
</assignedPerson>
</assignedAuthor>
</author>
<author>
<time value="20140325162115.306-0400"/>
<assignedAuthor>
<id root="1.3.6.1.4.1.12045.1" extension="EHDC"/>
<addr><streetAddressLine>5501 Dillard Dr</streetAddressLine><city>Cary</city><state>NC</state><postalCode>27518</postalCode></addr>
<telecom value="tel:+1-(877)599-5123" use="WP"/>
<assignedAuthoringDevice>
<manufacturerModelName>Medfusion Electronic Health Data Channel v1.1</manufacturerModelName>
<softwareName>Medfusion Electronic Health Data Channel v1.1</softwareName>
</assignedAuthoringDevice>
<representedOrganization>
<id root="1.3.6.1.4.1.12045"/>
<name>Medfusion, Inc.</name>
<telecom value="tel:+1-(877)599-5123" use="WP"/>
<addr><streetAddressLine>5501 Dillard Dr</streetAddressLine><city>Cary</city><state>NC</state><postalCode>27518</postalCode></addr>
</representedOrganization>
</assignedAuthor>
</author>
<informant>
<assignedEntity>
<id root="1.3.6.1.4.1.12045.1.30.1" extension="97c2f15c-e46d-48f6-bff9-1da69df968d1"/>
<addr><streetAddressLine>Buck Jones Road</streetAddressLine><city>Raleigh</city><state>NC</state><postalCode>12345</postalCode></addr>
<telecom value="tel:+1(123)456-7980"/>
<assignedPerson>
<name><family>DE7933_1</family><given>DE7933_1</given></name>
</assignedPerson>
</assignedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="1.3.6.1.4.1.12045"/>
<name>Medfusion</name>
<telecom value="tel:+1-(877)599-5123" use="WP"/>
<addr><streetAddressLine>5501 Dillard Dr</streetAddressLine><city>Cary</city><state>NC</state><postalCode>27518</postalCode></addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<participant typeCode="IND">
<associatedEntity classCode="PRS">
<id root="899b721a-d202-4131-99cc-4f9b4c24e47b" extension="789"/> <!-- This establihes the id by including the entity information -->
<code code="HUSB" displayName="Husband" codeSystem="2.16.840.1.113883.5.111" codeSystemName="Role Code"></code>
<addr><streetAddressLine>Buck Jones Road</streetAddressLine><city>Raleigh</city><state>NC</state><postalCode>12345</postalCode></addr>
<telecom value="tel:+1(123)456-7980"/>
<associatedPerson>
<name><family>Smith</family><given>Ralph</given></name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode="NOT">
<associatedEntity classCode="ECON">
<id root="899b721a-d202-4131-99cc-4f9b4c24e47b" extension="789"/> <!-- This id points to the patient's husband -->
<!--<addr nullFlavor="NA"/>
<associatedPerson>
<name><given>emrgency</given></name>
</associatedPerson>-->
</associatedEntity>
</participant>
<participant typeCode="IND">
<associatedEntity classCode="EMP">
<id root="899b721a-d202-4131-99cc-4f9b4c24e47b" extension="123"/> <!-- This id points to the patient role -->
<scopingOrganization>
<name>primary employer</name>
</scopingOrganization>
</associatedEntity>
</participant>
<participant typeCode="IND">
<associatedEntity classCode="EMP">
<id root="899b721a-d202-4131-99cc-4f9b4c24e47b" extension="789"/> <!-- This id points to the patient's husband -->
<scopingOrganization>
<name>secondary employer</name>
</scopingOrganization>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<id nullFlavor="NA"/>
<effectiveTime>
<low nullFlavor="UNK"/>
<high value="20140325162115.317-0400"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="RP" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role"/>
<time>
<low nullFlavor="UNK"/>
<high nullFlavor="UNK"/>
</time>
<assignedEntity>
<id root="ea24e737-f4a5-4f38-9efd-4b66abdc6986"/>
<code/>
<addr><state>AL</state></addr>
<telecom nullFlavor="NA"/>
<assignedPerson>
<name/>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.18"/>
<code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payers"/>
<title>payers</title>
<text><list><item>primary insurance name</item><item/><item/></list><list><item>secondary insurance name</item><item/><item/></list></text>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.60"/> <!-- Coverage Activity -->
<id root="2.16.840.1.113883.3.184" extension="P123457"/> <!-- Don't put this id here. DSTU Comment #997 -->
<id root="45e897b6-cc90-4e15-bf23-e1f16cb2318a"/>
<code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment Sources"/>
<statusCode code="completed"/> <!-- Should this statusCode be active? -->
<!-- ************** first policy - which really should be a "payment activity ****************** -->
<entryRelationship typeCode="COMP">
<sequenceNumber value="1"/>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.61"/><!-- Policy Activity -->
<id root="899e030b-b866-4b95-9a08-81265e4a5bce"/>
<code nullFlavor="UNK"/>
<statusCode code="completed"/>
<performer typeCode="PRF"> <!-- This is the payer --> <!-- How do we show self pay? In some cases, is the guarantor the payer too? -->
<templateId root="2.16.840.1.113883.10.20.22.4.88"/>
<assignedEntity> <!-- Who is really the right entity here? -->
<id root="2.16.840.1.113883.3.184" extension="P123456"/> <!-- Should be the policy id -->
<code code="PAYOR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleClassRelationship"/>
<addr><streetAddressLine>primary claims address</streetAddressLine><city>primary claims city</city><state>AL</state><postalCode>11111</postalCode></addr>
<telecom value="tel:+1(111)111-1111"/>
<representedOrganization>
<name>primary insurance name</name>
<telecom value="tel:+1(111)111-1111"/>
<addr><streetAddressLine>primary claims address</streetAddressLine><city>primary claims city</city><state>AL</state><postalCode>11111</postalCode></addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF"> <!-- This is the Insurance Company, ie Guarantor -->
<templateId root="2.16.840.1.113883.10.20.22.4.87"/>
<assignedEntity>
<id root="b8cd56b1-d151-4466-a913-26c166d72b4a"/>
<code code="GUAR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleCode"/>
<addr><streetAddressLine>primary claims address</streetAddressLine><city>primary claims city</city><state>AL</state><postalCode>11111</postalCode></addr>
<telecom value="tel:+1(111)111-1111"/>
<representedOrganization>
<name>primary insurance name</name>
<telecom value="tel:+1(111)111-1111"/>
<addr><streetAddressLine>primary claims address</streetAddressLine><city>primary claims city</city><state>AL</state><postalCode>11111</postalCode></addr>
</representedOrganization>
</assignedEntity>
</performer>
<participant typeCode="HLD"> <!-- This is the policy holder -->
<templateId root="2.16.840.1.113883.10.20.22.4.90"/>
<participantRole classCode="HLD">
<id root="2.16.840.1.113883.3.184" extension="123"/> <!-- This is the id of the holder of the first policy --> <!-- This is the person who needs to be recorded in the header with their role as employee. -->
<code code="POLHOLD" displayName="Policy Holder" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleCode" ></code>
<addr><streetAddressLine>primary policy street</streetAddressLine><city>primary policy city</city><state>AL</state><postalCode>12345</postalCode></addr>
<telecom value="tel:+1(111)111-1111"/>
<playingEntity>
<name><given>primary policy first name</given><family>primary policy last name</family></name>
<sdtc:birthTime value="20131231190000.000-0500"/>
</playingEntity>
</participantRole>
</participant>
<participant typeCode="COV"> <!-- This is the covered person -->
<templateId root="2.16.840.1.113883.10.20.22.4.89"/>
<participantRole classCode="PAT">
<id root="899b721a-d202-4131-99cc-4f9b4c24e47b" extension="123"/> <!-- This id should be meaningful to the authoring system as the patient's id. -->
<code code="SELF" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="Self"/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
</participantRole>
</participant>
</act>
</entryRelationship>
<!-- ************** second policy ****************** -->
<entryRelationship typeCode="COMP">
<sequenceNumber value="2"/>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.61"/><!-- Policy Activity -->
<id root="45e897b6-cc90-4e15-bf23-e1f16cb2318a"/>
<id root="899e030b-b866-4b95-9a08-81265e4a5bce" extension="7890"/>
<code nullFlavor="UNK"/>
<statusCode code="completed"/>
<performer typeCode="PRF"> <!-- This is the payer --> <!-- How do we show self pay? In some cases, is the guarantor the payer too? -->
<templateId root="2.16.840.1.113883.10.20.22.4.88"/>
<assignedEntity> <!-- Who is really the right entity here? -->
<id root="2.16.840.1.113883.3.184" extension="P789123"/><!-- This is the id of the holder of the second policy -->
<id root="45e897b6-cc90-4e15-bf23-e1f16cb2318a"/>
<code code="PAYOR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleClassRelationship"/>
<addr><streetAddressLine>secondary claims address</streetAddressLine><city>secondary city</city><state>AK</state><postalCode>22222</postalCode></addr>
<telecom value="tel:+1(222)222-2222"/>
<representedOrganization>
<name>secondary insurance name</name>
<telecom value="tel:+1(222)222-2222"/>
<addr><streetAddressLine>secondary claims address</streetAddressLine><city>secondary city</city><state>AK</state><postalCode>22222</postalCode></addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF"> <!-- This is the second Insurance Company, ie Guarantor -->
<templateId root="2.16.840.1.113883.10.20.22.4.87"/>
<assignedEntity>
<id root="45e897b6-cc90-4e15-bf23-e1f16cb2318a"/>
<code code="GUAR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleClassRelationship"/>
<addr><streetAddressLine>secondary claims address</streetAddressLine><city>secondary city</city><state>AK</state><postalCode>22222</postalCode></addr>
<telecom value="tel:+1(222)222-2222"/>
<representedOrganization>
<name>secondary insurance name</name>
<telecom value="tel:+1(222)222-2222"/>
<addr><streetAddressLine>secondary claims address</streetAddressLine><city>secondary city</city><state>AK</state><postalCode>22222</postalCode></addr>
</representedOrganization>
</assignedEntity>
</performer>
<participant typeCode="HLD">
<templateId root="2.16.840.1.113883.10.20.22.4.90"/>
<participantRole classCode="HLD">
<id root="2.16.840.1.113883.3.184" extension="789"/><!-- This is the id of the holder of the second policy -->
<code code="POLHOLD" displayName="Policy Holder" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7 RoleCode" ></code>
<addr><streetAddressLine>secondary policy street</streetAddressLine><city>secondary policy city</city><state>AK</state><postalCode>22222</postalCode></addr>
<telecom value="tel:+1(222)222-2222"/>
<playingEntity>
<name><given>secondary policy first name</given><family>secondary policy last name</family></name>
<sdtc:birthTime value="20131231190000.000-0500"/>
</playingEntity>
</participantRole>
</participant>
<participant typeCode="COV"> <!-- This is the covered person -->
<templateId root="2.16.840.1.113883.10.20.22.4.89"/>
<participantRole classCode="PAT">
<id root="899b721a-d202-4131-99cc-4f9b4c24e47b" extension="123"/> <!-- This id should be meaningful to the authoring system as the patient's id. -->
<code code="SELF" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="Self"/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
</participantRole>
</participant>
</act>
</entryRelationship>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>