{
  "resourceType" : "ClaimResponse",
  "id" : "ReferralAuthorizationResponseExample",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ClaimResponse</b><a name=\"ReferralAuthorizationResponseExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ClaimResponse &quot;ReferralAuthorizationResponseExample&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claimresponse.html\">PAS Claim Response</a></p></div><p><b>identifier</b>: id:\u00a0111099</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"Patient-SubscriberExample.html\">Patient/SubscriberExample</a> &quot; SMITH&quot;</p><p><b>created</b>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization/InsurerExample</a> &quot;MARYLAND CAPITAL INSURANCE COMPANY&quot;</p><p><b>requestor</b>: <a href=\"Organization-UMOExample.html\">Organization/UMOExample</a> &quot;DR. JOE SMITH CORPORATION&quot;</p><p><b>outcome</b>: complete</p><blockquote><p><b>item</b></p><p><b>ItemRequestedServiceDate</b>: 2005-05-02 --&gt; 2005-06-02</p><p><b>ItemPreAuthIssueDate</b>: 2005-05-02</p><p><b>ItemPreAuthPeriod</b>: 2005-05-02 --&gt; 2005-06-02</p><blockquote><p><b>ItemAuthorizedProvider</b></p><blockquote><p><b>url</b></p><code>provider</code></blockquote><p><b>value</b>: <a href=\"Practitioner-ReferralPractitionerExample.html\">Practitioner/ReferralPractitionerExample</a> &quot; WATSON&quot;</p></blockquote><blockquote><p><b>ItemAuthorizedDetail</b></p><blockquote><p><b>url</b></p><code>productOrServiceCode</code></blockquote><p><b>value</b>: Consultation <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#3)</span></p><blockquote><p><b>url</b></p><code>unitPrice</code></blockquote><p><b>value</b>: <span title=\"US Dollar\">US$100.00</span> (USD)</p><blockquote><p><b>url</b></p><code>quantity</code></blockquote><p><b>value</b>: 1</p></blockquote><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></td></tr></table></blockquote></div>"
  },
  "identifier" : [{
    "system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
    "value" : "111099",
    "assigner" : {
      "identifier" : {
        "system" : "http://example.org/USER_ASSIGNED",
        "value" : "9012345678"
      }
    }
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "professional"
    }]
  },
  "use" : "preauthorization",
  "patient" : {
    "reference" : "Patient/SubscriberExample"
  },
  "created" : "2005-05-02T11:02:00+05:00",
  "insurer" : {
    "reference" : "Organization/InsurerExample"
  },
  "requestor" : {
    "reference" : "Organization/UMOExample"
  },
  "outcome" : "complete",
  "item" : [{
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate",
      "valuePeriod" : {
        "start" : "2005-05-02",
        "end" : "2005-06-02"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",
      "valueDate" : "2005-05-02"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",
      "valuePeriod" : {
        "start" : "2005-05-02",
        "end" : "2005-06-02"
      }
    },
    {
      "extension" : [{
        "url" : "provider",
        "valueReference" : {
          "reference" : "Practitioner/ReferralPractitionerExample"
        }
      }],
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider"
    },
    {
      "extension" : [{
        "url" : "productOrServiceCode",
        "valueCodeableConcept" : {
          "coding" : [{
            "system" : "https://codesystem.x12.org/005010/1365",
            "code" : "3",
            "display" : "Consultation"
          }]
        }
      },
      {
        "url" : "unitPrice",
        "valueMoney" : {
          "value" : 100,
          "currency" : "USD"
        }
      },
      {
        "url" : "quantity",
        "valueQuantity" : {
          "value" : 1
        }
      }],
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail"
    }],
    "itemSequence" : 1,
    "adjudication" : [{
      "extension" : [{
        "extension" : [{
          "url" : "number",
          "valueString" : "AUTH0001"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
          "valueCodeableConcept" : {
            "coding" : [{
              "system" : "https://codesystem.x12.org/005010/306",
              "code" : "A1",
              "display" : "Certified in total"
            }]
          }
        }],
        "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
      }],
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "submitted"
        }]
      }
    }]
  }]
}