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Resource "UR3503" Version "1" (ClaimResponse)

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XML or JSON representation . provenance for this resource

A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.

{
  "resourceType" : "ClaimResponse",
  "id" : "UR3503",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.286Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>"
  },
  "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" : 250.00,
        "currency" : "USD"
      },
      "noteNumber" : [
        "101"
      ],
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "code" : "eligible"
              }
            ]
          },
          "amount" : {
            "value" : 250.00,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "copay"
              }
            ]
          },
          "amount" : {
            "value" : 10.00,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "eligpercent"
              }
            ]
          },
          "value" : 100.00
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "benefit"
              }
            ]
          },
          "amount" : {
            "value" : 240.00,
            "currency" : "USD"
          }
        }
      ]
    },
    {
      "itemSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/oralservicecodes",
            "code" : "2101",
            "display" : "Radiograph, series (12)"
          }
        ]
      },
      "net" : {
        "value" : 800.00,
        "currency" : "USD"
      },
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "code" : "eligible"
              }
            ]
          },
          "amount" : {
            "value" : 800.00,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "eligpercent"
              }
            ]
          },
          "value" : 100.00
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "benefit"
              }
            ]
          },
          "amount" : {
            "value" : 800.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "total" : [
    {
      "category" : {
        "coding" : [
          {
            "code" : "submitted"
          }
        ]
      },
      "amount" : {
        "value" : 1050.00,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "code" : "benefit"
          }
        ]
      },
      "amount" : {
        "value" : 1040.00,
        "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"
      }
    }
  ]
}