| 1 | <component>
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| 2 | <section>
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| 3 | <!--We are including only a coverage activity for Medicare here. There is also policy activity and and authorization activity that I don't think we need to report for QRDA, at least not for most reports-->
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| 4 | <templateId root="2.16.840.1.113883.10.20.1.9"/>
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| 5 | <!-- 48768-6 is payment sources and is fixed CQ-188,189,190-->
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| 6 | <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment Sources"/>
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| 7 | <!--CQ-191,192-->
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| 8 | <title>Payers</title>
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| 9 | <text>
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| 10 | </text>
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| 11 | <!--medicare-->
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| 12 | <entry typeCode="DRIV">
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| 13 | <!--WVP moodCode is DEF is definition to describe the characteristics of who must be involved in an act CQ-194,195-->
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| 14 | <act classCode="ACT" moodCode="DEF">
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| 15 | <!--WVP coverage activity template is the 10.20.1.20 CQ-193-->
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| 16 | <templateId root="2.16.840.1.113883.10.20.1.20"/>
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| 17 | <!--Coverage Shall Include and Act ID CQ-196-->
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| 18 | <!--looks like a UUID to me-->
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| 19 | <id root="2.16.840.1.113883.3.543" extension="@@@UUID-PAYER@@@"/><!--FIX!!!???-->
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| 20 | <!--CQ-197-198 It appears that statusCode="completed" need to follow the code code ... here and below-->
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| 21 |
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| 22 | <!--CQ199,200-->
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| 23 | <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment sources"/>
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| 24 | <statusCode code="completed"/>
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| 25 |
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| 26 | <!--A coverage activity shall contain on or more act/entryRelationship. The value for act/entryRelationship/@typeCode shall be COMP which SHALL be the CMS QRDA Policy Activity CQ-201, 203-->
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| 27 | <!--It MAY contain an entryRelationship/sequenceNumber CQ-202-->
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| 28 | <entryRelationship typeCode="COMP">
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| 29 | <!-- for the act is event with moodCode EVN CQ-205,206,207-->
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| 30 | <act classCode="ACT" moodCode="EVN">
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| 31 | <!--Policy activity is the 10.20.1.26 template CQ-205-->
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| 32 | <templateId root="2.16.840.1.113883.10.20.1.26"/>
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| 33 | <templateId root="2.16.840.1.113883.3.249.11.100.7"/>
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| 34 |
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| 35 | <!-- act/id which is the group or contract number related to the insurance policy or program CQ-208-->
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| 36 | <id root="dbbb6311-8a4d-11df-a4ee-0800200c9c66"/><!--!!!FIX-->
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| 37 | <!--Act statusCode must be completed CQ-210-->
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| 38 | <!--This SHOULD be present and comes from the downloadable resource S display name is in quotes AUTOPOL - "automobile" policy;EHCPOL additional insurance in addition to Medicare in this case
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| 39 | HSAPOL "Health Spending Account";PUBLICPOL "public healthcare" which is NOT Medicare - maybe a state program for example
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| 40 | WBCPOL is "workers compensation" CQ-211,212-->
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| 41 | <!--<code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4" displayName="Public Healthcare"/>-->
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| 42 | <code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4" displayName="Public Healthcare"/>
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| 43 | <!--WVP performer type codes are numerous but PRF is performer representing the Payer CQ-213-->
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| 44 | <statusCode code="completed"/>
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| 45 | <performer typeCode="PRF">
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| 46 |
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| 47 | <!--performer/assignedEntity id is the payer identification and the extension comes from the downloadable resource section I insurance plan TYPE CQ-214-->
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| 48 | <assignedEntity>
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| 49 | <id root="2.16.840.1.113883.12.86" extension="MC"/>
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| 50 | <!--<representedOrganization>
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| 51 | <name>CMS</name>
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| 52 | </representedOrganization>-->
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| 53 | </assignedEntity>
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| 54 | </performer>
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| 55 | <!-- Act/participant @typeCode this represents the covered party CQ-215-->
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| 56 | <participant typeCode="COV">
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| 57 | <participantRole>
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| 58 | <!--A covered party in a policy activity SHOULD contain one or more participant/participantRole/id to represent the patien's member of subscriber identifier with respect to the payer
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| 59 | For participant/paricipantRole/id either the Social Security Number or HIC Number SHALL be submitted for Medicare patients. for SSN the ID @root SHALL be 2.16.840.1.113883.4.1 where
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| 60 | the HIC id/@root shall be 2.16.840.1.113883.3.249.13 CQ-216"RoleCode" in the downloadable resource-->
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| 61 | <!-- in this case theextension is the patients SSN for a medicare patient so it is the same each time for one patient-->
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| 62 | <id root="2.16.840.1.113883.4.1" extension="@@SSN@@"/>
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| 63 | <!--The covered party in tha policy activity SHOULD contain exactly one particpant/participantRole/code for self, family etc from the valuse set PolicyOrPrograCoverageRoleType 2.16.840.1.113883.1.11.19809 CQ-217,218-->
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| 64 | <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self"/>
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| 65 | </participantRole>
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| 66 | </participant>
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| 67 | </act>
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| 68 | </entryRelationship>
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| 69 | </act>
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| 70 | </entry>
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| 71 | </section>
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| 72 | </component>
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