Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
<section xmlns="urn:hl7-org:v3">
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<!-- ******** Payers section template ******** -->
<code displayName="Payers" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="48768-6"/>
<title>Insurance Providers</title>
<text>
. . .
</text>
<entry typeCode="DRIV">
<act moodCode="EVN" classCode="ACT">
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<id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66"/>
<code displayName="Payment sources" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="52556-8"/>
<text/>
<statusCode code="completed"/>
<effectiveTime value="20230501"/>
<entryRelationship typeCode="COMP">
<sequenceNumber value="2"/>
<act moodCode="EVN" classCode="ACT">
<!-- Policy Activity -->
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<id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66"/>
<code displayName="MEDICARE" codeSystemName="SOP"
codeSystem="2.16.840.1.113883.3.221.5" code="1"/>
<text/>
<statusCode code="completed"/>
<performer typeCode="PRF">
<templateId root="2.16.840.1.113883.10.20.22.4.87"/>
<assignedEntity>
<id root="2.16.840.1.113883.19"/>
<code codeSystemName="HL7 RoleCode"
codeSystem="2.16.840.1.113883.5.110" code="PAYOR"/>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
<addr use="WP">
<streetAddressLine>123 Insurance Road</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</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>
<participant typeCode="COV">
<!-- Coverage Target -->
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<time>
<low value="20130905"/>
<high value="20150905"/>
</time>
<participantRole>
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<code displayName="self" codeSystemName="RoleCode"
codeSystem="2.16.840.1.113883.5.111" code="SELF"/>
<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:sdtcBirthTime xmlns:sdtc="urn:hl7-org:sdtc"
value="19620206"/>
</playingEntity>
</participantRole>
</participant>
</act>
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</act>
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