{
"resourceType": "ClaimResponse", "id": "UR3503", "identifier": [ { "system": "http://www.SocialBenefitsInc.com/fhir/ClaimResponse", "value": "UR3503" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "oral" } ] }, "use": "preauthorization", "patient": { "reference": "Patient/1" }, "created": "2014-08-16", "insurer": { "identifier": { "system": "http://www.jurisdiction.org/insurers", "value": "444123" } }, "requestor": { "reference": "Organization/1" }, "outcome": "complete", "disposition": "The enclosed services are authorized for your provision within 30 days of this notice.", "preAuthRef": "18SS12345", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "addItem": [ { "itemSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://example.org/fhir/oralservicecodes", "code": "1101" } ] }, "modifier": [ { "coding": [ { "system": "http://example.org/fhir/modifiers", "code": "x", "display": "None" } ] } ], "net": { "value": 250.0, "currency": "USD" }, "noteNumber": [ 101 ], "adjudication": [ { "category": { "coding": [ { "code": "eligible" } ] }, "amount": { "value": 250.0, "currency": "USD" } }, { "category": { "coding": [ { "code": "copay" } ] }, "amount": { "value": 10.0, "currency": "USD" } }, { "category": { "coding": [ { "code": "eligpercent" } ] }, "value": 100.0 }, { "category": { "coding": [ { "code": "benefit" } ] }, "amount": { "value": 240.0, "currency": "USD" } } ] }, { "itemSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://example.org/fhir/oralservicecodes", "code": "2101", "display": "Radiograph, series (12)" } ] }, "net": { "value": 800.0, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "code": "eligible" } ] }, "amount": { "value": 800.0, "currency": "USD" } }, { "category": { "coding": [ { "code": "eligpercent" } ] }, "value": 100.0 }, { "category": { "coding": [ { "code": "benefit" } ] }, "amount": { "value": 800.0, "currency": "USD" } } ] } ], "total": [ { "category": { "coding": [ { "code": "submitted" } ] }, "amount": { "value": 1050.0, "currency": "USD" } }, { "category": { "coding": [ { "code": "benefit" } ] }, "amount": { "value": 1040.0, "currency": "USD" } } ], "processNote": [ { "number": 101, "type": "print", "text": "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.", "language": { "coding": [ { "system": "urn:ietf:bcp:47", "code": "en-CA" } ] } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "Coverage/9876B1" } } ], "meta": { "tag": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason", "code": "HTEST", "display": "test health data" } ] }
}