{

"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"
    }
  ]
}

}