<creation value="2025-03-30" /> </valueAttachment> </supportingInfo> <supportingInfo> <sequence value="2" /> <category> <coding> <code value="patientEvent" /> </coding> </category> <timingPeriod> <start value="2026-03-05" /> <end value="2026-03-05" /> </timingPeriod> </supportingInfo> <supportingInfo> <sequence value="3" /> <category> <coding> <code value="additionalInformation" /> </coding> </category> <valueReference> <reference value="DocumentReference/DocumentReference" /> </valueReference> </supportingInfo> <diagnosis> <sequence value="1" /> <diagnosisCodeableConcept> <coding> <code value="A0104" /> </coding> </diagnosisCodeableConcept> <type> <coding> <code value="ABF" /> </coding> </type> </diagnosis> <diagnosis> <sequence value="2" /> <diagnosisCodeableConcept> <coding> <code value="A0101" /> </coding> </diagnosisCodeableConcept> <type> <coding> <code value="ABF" /> </coding> </type> </diagnosis> <diagnosis> <sequence value="3" /> <diagnosisCodeableConcept> <coding> <code value="A0102" /> </coding> </diagnosisCodeableConcept> <type> <coding> <code value="ABF" /> </coding> </type> </diagnosis> <diagnosis> <sequence value="4" /> <diagnosisCodeableConcept> <coding> <code value="A0103" /> </coding> </diagnosisCodeableConcept> <type> <coding> <code value="ABF" /> </coding> </type> </diagnosis> <insurance> <sequence value="1" /> <focal value="true" /> <coverage> <reference value="Coverage/InsuranceExample" /> </coverage> </insurance> <item> <extension url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber"> <valueString value="100004513" /> </extension> <extension url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType"> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct" /> <code value="HS" /> <display value="Health Services Review" /> </coding> </valueCodeableConcept> </extension> <sequence value="1" /> <category> <coding> <code value="1" /> </coding> </category> <productOrService> <coding> <system value="http://www.ama-assn.org/go/cpt" /> <code value="99212" /> </coding> </productOrService> <servicedPeriod> <start value="2026-03-05" /> <end value="2026-03-05" /> </servicedPeriod> <locationCodeableConcept> <coding> <system value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" /> <code value="22" /> </coding> </locationCodeableConcept> <quantity> <value value="125" /> <unit value="UN" /> </quantity> </item> </Claim> </resource> </entry> <entry> <fullUrl value="http://example.org/fhir/Organization/UMOExample" /> <resource> <Organization> <id value="UMOExample" /> <identifier> <type> <coding> <code value="NPI" /> </coding> </type> <system value="http://hl7.org/fhir/sid/us-npi" /> <value value="1326085424" /> </identifier> <identifier> <type> <coding> <code value="TIN" /> </coding> </type> <system value="http://hl7.org/fhir/sid/us-npi" /> <value value="157892419" /> </identifier> <active value="false" /> <name value="JFK MEDICAL CENTER" /> <address> <line value="5301 S CONGRESS AVE" /> <city value="ATLANTIS" /> <state value="FL" /> <postalCode value="33462" /> <country value="US" /> </address> <contact> <name> <family value="LARSON" /> </name> <telecom> <system value="phone" /> <value value="5615482673" /> </telecom> </contact> </Organization> </resource> </entry> <entry> <fullUrl value="http://example.org/fhir/Organization/InsurerExample" /> <resource> <Organization> <id value="InsurerExample" /> <identifier> <type> <coding> <code value="NPI" /> </coding> </type> <system value="http://hl7.org/fhir/sid/us-npi" /> <value value="1578924155" /> </identifier> <identifier> <type> <coding> <code value="TIN" /> </coding> </type> <system value="http://hl7.org/fhir/sid/us-npi" /> <value value="157892419" /> </identifier> <active value="true" /> <type> <coding> <code value="professional" /> </coding> </type> <name value="HUMANA" /> </Organization> </resource> </entry> <entry> <fullUrl value="http://example.org/fhir/Coverage/InsuranceExample" /> <resource> <Coverage> <id value="InsuranceExample" /> <status value="cancelled" /> <subscriberId value="8779034545" /> <beneficiary> <reference value="Patient/SubscriberExample" /> </beneficiary> <relationship> <coding> <code value="18" /> </coding> <text value="Negative for Chlamydia Trachomatis rRNA" /> </relationship> <period> <start value="2025-03-27" /> <end value="2025-03-28" /> </period> <payor> <reference value="Organization/InsurerExample" /> </payor> </Coverage> </resource> </entry> <entry> <fullUrl value="http://example.org/fhir/Patient/SubscriberExample" /> <resource> <Patient> <id value="SubscriberExample" /> <identifier> <type> <coding> <code value="MI" /> </coding> </type> <system value="http://example.org/MIN" /> <value value="H5026770000" /> </identifier> <name> <family value="WATERIDGE" /> <given value="SUSBETH" /> </name> <gender value="male" /> <birthDate value="1948-11-15" /> <address> <line value="9677 GREEN HILL ROAD" /> <city value="SHELBYVILLE" /> <state value="KY" /> <postalCode value="40065" /> <country value="US" /> </address> </Patient> </resource> </entry> <entry> <fullUrl value="http://example.org/fhir/Practitioner/ReferralPractitionerExample" /> <resource> <Practitioner> <id value="ReferralPractitionerExample" /> <identifier> <type> <coding> <code value="NPI" /> </coding> </type> <system value="http://hl7.org/fhir/sid/us-npi" /> <value value="1295852101" /> </identifier> <identifier> <type> <coding> <code value="TIN" /> </coding> </type> <system value="http://hl7.org/fhir/sid/us-npi" /> <value value="157892419" /> </identifier> <name> <family value="AARON" /> <given value="JOSHUA" /> </name> <telecom> <system value="phone" /> <value value="8124248231" /> </telecom> <telecom> <system value="fax" /> <value value="8124358794" /> </telecom> <address> <line value="520 MARY ST STE 520" /> <city value="EVANSVILLE" /> <state value="IN" /> <postalCode value="47710" /> <country value="US" /> </address> </Practitioner> </resource> </entry> </Bundle>


  
    
    
      
        
        
          
            
              
              
              
            
          
        
        
          
            
              
              
              
            
          
        
        
          
            
              
              
              
            
          
        
        
      
    
  
  
    
    
      
        
        
          
            
          
        
        
          
            
              
            
          
          
        
        
        
          
            
          
        
        
        
          
        
        
        
          
        
        
          
        
        
          
            
          
        
        
          
            
          
          
          
            
          
          
            
              
              
            
          
          
            
              
            
          
        
        
          
            
          
          
          
            
          
          
            
              
              
            
          
          
            
              
            
          
        
        
          
          
            
              
            
          
          
            
            
            <creation value="2025-03-30" />
          </valueAttachment>
        </supportingInfo>
        <supportingInfo>
          <sequence value="2" />
          <category>
            <coding>
              <code value="patientEvent" />
            </coding>
          </category>
          <timingPeriod>
            <start value="2026-03-05" />
            <end value="2026-03-05" />
          </timingPeriod>
        </supportingInfo>
        <supportingInfo>
          <sequence value="3" />
          <category>
            <coding>
              <code value="additionalInformation" />
            </coding>
          </category>
          <valueReference>
            <reference value="DocumentReference/DocumentReference" />
          </valueReference>
        </supportingInfo>
        <diagnosis>
          <sequence value="1" />
          <diagnosisCodeableConcept>
            <coding>
              <code value="A0104" />
            </coding>
          </diagnosisCodeableConcept>
          <type>
            <coding>
              <code value="ABF" />
            </coding>
          </type>
        </diagnosis>
        <diagnosis>
          <sequence value="2" />
          <diagnosisCodeableConcept>
            <coding>
              <code value="A0101" />
            </coding>
          </diagnosisCodeableConcept>
          <type>
            <coding>
              <code value="ABF" />
            </coding>
          </type>
        </diagnosis>
        <diagnosis>
          <sequence value="3" />
          <diagnosisCodeableConcept>
            <coding>
              <code value="A0102" />
            </coding>
          </diagnosisCodeableConcept>
          <type>
            <coding>
              <code value="ABF" />
            </coding>
          </type>
        </diagnosis>
        <diagnosis>
          <sequence value="4" />
          <diagnosisCodeableConcept>
            <coding>
              <code value="A0103" />
            </coding>
          </diagnosisCodeableConcept>
          <type>
            <coding>
              <code value="ABF" />
            </coding>
          </type>
        </diagnosis>
        <insurance>
          <sequence value="1" />
          <focal value="true" />
          <coverage>
            <reference value="Coverage/InsuranceExample" />
          </coverage>
        </insurance>
        <item>
          <extension url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber">
            <valueString value="100004513" />
          </extension>
          <extension url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
            <valueCodeableConcept>
              <coding>
                <system value="http://snomed.info/sct" />
                <code value="HS" />
                <display value="Health Services Review" />
              </coding>
            </valueCodeableConcept>
          </extension>
          <sequence value="1" />
          <category>
            <coding>
              <code value="1" />
            </coding>
          </category>
          <productOrService>
            <coding>
              <system value="http://www.ama-assn.org/go/cpt" />
              <code value="99212" />
            </coding>
          </productOrService>
          <servicedPeriod>
            <start value="2026-03-05" />
            <end value="2026-03-05" />
          </servicedPeriod>
          <locationCodeableConcept>
            <coding>
              <system value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" />
              <code value="22" />
            </coding>
          </locationCodeableConcept>
          <quantity>
            <value value="125" />
            <unit value="UN" />
          </quantity>
        </item>
      </Claim>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Organization/UMOExample" />
    <resource>
      <Organization>
        <id value="UMOExample" />
        <identifier>
          <type>
            <coding>
              <code value="NPI" />
            </coding>
          </type>
          <system value="http://hl7.org/fhir/sid/us-npi" />
          <value value="1326085424" />
        </identifier>
        <identifier>
          <type>
            <coding>
              <code value="TIN" />
            </coding>
          </type>
          <system value="http://hl7.org/fhir/sid/us-npi" />
          <value value="157892419" />
        </identifier>
        <active value="false" />
        <name value="JFK MEDICAL CENTER" />
        <address>
          <line value="5301 S CONGRESS AVE" />
          <city value="ATLANTIS" />
          <state value="FL" />
          <postalCode value="33462" />
          <country value="US" />
        </address>
        <contact>
          <name>
            <family value="LARSON" />
          </name>
          <telecom>
            <system value="phone" />
            <value value="5615482673" />
          </telecom>
        </contact>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Organization/InsurerExample" />
    <resource>
      <Organization>
        <id value="InsurerExample" />
        <identifier>
          <type>
            <coding>
              <code value="NPI" />
            </coding>
          </type>
          <system value="http://hl7.org/fhir/sid/us-npi" />
          <value value="1578924155" />
        </identifier>
        <identifier>
          <type>
            <coding>
              <code value="TIN" />
            </coding>
          </type>
          <system value="http://hl7.org/fhir/sid/us-npi" />
          <value value="157892419" />
        </identifier>
        <active value="true" />
        <type>
          <coding>
            <code value="professional" />
          </coding>
        </type>
        <name value="HUMANA" />
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Coverage/InsuranceExample" />
    <resource>
      <Coverage>
        <id value="InsuranceExample" />
        <status value="cancelled" />
        <subscriberId value="8779034545" />
        <beneficiary>
          <reference value="Patient/SubscriberExample" />
        </beneficiary>
        <relationship>
          <coding>
            <code value="18" />
          </coding>
          <text value="Negative for Chlamydia Trachomatis rRNA" />
        </relationship>
        <period>
          <start value="2025-03-27" />
          <end value="2025-03-28" />
        </period>
        <payor>
          <reference value="Organization/InsurerExample" />
        </payor>
      </Coverage>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Patient/SubscriberExample" />
    <resource>
      <Patient>
        <id value="SubscriberExample" />
        <identifier>
          <type>
            <coding>
              <code value="MI" />
            </coding>
          </type>
          <system value="http://example.org/MIN" />
          <value value="H5026770000" />
        </identifier>
        <name>
          <family value="WATERIDGE" />
          <given value="SUSBETH" />
        </name>
        <gender value="male" />
        <birthDate value="1948-11-15" />
        <address>
          <line value="9677 GREEN HILL ROAD" />
          <city value="SHELBYVILLE" />
          <state value="KY" />
          <postalCode value="40065" />
          <country value="US" />
        </address>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Practitioner/ReferralPractitionerExample" />
    <resource>
      <Practitioner>
        <id value="ReferralPractitionerExample" />
        <identifier>
          <type>
            <coding>
              <code value="NPI" />
            </coding>
          </type>
          <system value="http://hl7.org/fhir/sid/us-npi" />
          <value value="1295852101" />
        </identifier>
        <identifier>
          <type>
            <coding>
              <code value="TIN" />
            </coding>
          </type>
          <system value="http://hl7.org/fhir/sid/us-npi" />
          <value value="157892419" />
        </identifier>
        <name>
          <family value="AARON" />
          <given value="JOSHUA" />
        </name>
        <telecom>
          <system value="phone" />
          <value value="8124248231" />
        </telecom>
        <telecom>
          <system value="fax" />
          <value value="8124358794" />
        </telecom>
        <address>
          <line value="520 MARY ST STE 520" />
          <city value="EVANSVILLE" />
          <state value="IN" />
          <postalCode value="47710" />
          <country value="US" />
        </address>
      </Practitioner>
    </resource>
  </entry>
</Bundle>