---

Generated Narrative: Composition

status: FINAL

type: Coverage Transition Document (PCDE Temporary Codes#pcde)

date: 2019-07-21 11:09:00+0700

author: Practitioner/1

title: Coverage Decision Exchange Document (Joe Smith, 2019-07-21)

Events

-	Detail
*	Coverage/1

---

• CarePlan/1

• Claim/1
• ClaimResponse/1

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.

• DocumentReference/1

---

Additional Document Content

---

2. http://originalinsuranceinc.com/fhir/Patient/1 (Patient/1)

JOE SMITH Male, DoB: ( id: 444222222)

---

3. http://originalinsuranceinc.com/fhir/Coverage/1 (Coverage/1)

Generated Narrative: Coverage

Resource Coverage "1"

status: ACTIVE

subscriberId: id: 12345678

beneficiary: Patient/1

payor: Organization/1

---

4. http://originalinsuranceinc.com/fhir/Organization/1 (Organization/1)

Generated Narrative: Organization

Resource Organization "1"

identifier: id: 789312

active: true

name: MARYLAND CAPITAL INSURANCE COMPANY

---

5. http://originalinsuranceinc.com/fhir/CarePlan/1 (CarePlan/1)

Generated Narrative: CarePlan

Resource CarePlan "1"

instantiatesUri: http://originalinsuranceinc.com/consultReviewURI

status: ACTIVE

intent: PLAN

category: Assessment and Plan of Treatment (US Core CarePlan Category Extension Codes#assess-plan)

subject: Patient/1

---

6. http://originalinsuranceinc.com/fhir/Claim/1 (Claim/1)

Generated Narrative: Claim

Resource Claim "1"

identifier: id: 111099

status: ACTIVE

type: Professional (Claim Type Codes#professional)

use: PREAUTHORIZATION

patient: Patient/1

created: 2019-07-20

insurer: Organization/1

provider: http://example.org/fhir/Organization/provider

priority: Normal (Process Priority Codes#normal)

CareTeams

-	Sequence	Provider
*	1	http://example.org/fhir/Organization/provider

Diagnoses

-	Sequence	Diagnosis[x]
*	1	Chronic pain syndrome (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#G89.4)

Insurances

-	Sequence	Focal	Coverage
*	1	true	Coverage/1

Items

-	Extension	Sequence	CareTeamSequence	DiagnosisSequence	ProductOrService	Location[x]
*	, ,	1	1	1	Consultation (1365#3)	11 (CMS Place of Service Codes (POS)#11)

---

7. http://originalinsuranceinc.com/fhir/ClaimResponse/1 (ClaimResponse/1)

Generated Narrative: ClaimResponse

Resource ClaimResponse "1"

identifier: id: 111099

status: ACTIVE

type: Professional (Claim Type Codes#professional)

use: PREAUTHORIZATION

patient: Patient/1

created: 2019-07-20

insurer: Organization/1

requestor: http://example.org/fhir/Organization/provider

outcome: COMPLETE

item

ReviewAction

value: AUTH0001

value: Certified in total (306#A1)

AuthorizedDate: 2005-05-02 --> 2005-06-02

itemSequence: 1

Adjudications

-	Category
*	Submitted Amount (Adjudication Value Codes#submitted)

---

8. http://originalinsuranceinc.com/fhir/Practitioner/1 (Practitioner/1)

Generated Narrative: Practitioner

Resource Practitioner "1"

identifier: id: 8189991234

name: JAMES GARDENER

---

9. http://originalinsuranceinc.com/fhir/ServiceRequest/1 (ServiceRequest/1)

Generated Narrative: ServiceRequest

Resource ServiceRequest "1"

status: ACTIVE

intent: ORDER

code: Consultation (1365#3)

quantity: 1 VS

subject: Patient/1

performer: PractitionerRole/1

---

10. http://originalinsuranceinc.com/fhir/Condition/1 (Condition/1)

Generated Narrative: Condition

Resource Condition "1"

category: Encounter Diagnosis (Condition Category Codes#encounter-diagnosis)

code: Acute myocardial infarction of unspecified site, episode of care unspecified (icd-9-cm#410.90)

subject: Patient/1

recordedDate: 2005-04-30

---

11. http://originalinsuranceinc.com/fhir/PractitionerRole/1 (PractitionerRole/1)

Generated Narrative: PractitionerRole

Resource PractitionerRole "1"

practitioner: Practitioner/2

code: Provider (ENTITY_IDENTIFIER_CODE#1P)

---

12. http://originalinsuranceinc.com/fhir/Practitioner/2 (Practitioner/2)

Generated Narrative: Practitioner

Resource Practitioner "2"

identifier: id: 987654321

name: SUSAN WATSON

telecom: ph: 4029993456

---

13. http://originalinsuranceinc.com/fhir/DocumentReference/1 (DocumentReference/1)

Generated Narrative: DocumentReference

Resource DocumentReference "1"

status: CURRENT

docStatus: FINAL

type: Discharge summary (LOINC#18842-5)

subject: Patient/1

author: Practitioner/1

content