Publication Build: This will be filled in by the publication tooling
| Page standards status: Informative |
Generated Narrative: ClaimResponse
Resource ClaimResponse "PractitionerRequestorResponseExample"
Profile: PAS Claim Response
identifier: id: 111099
status: active
type: Professional (Claim Type Codes#professional)
use: preauthorization
patient: Patient/SubscriberExample " SMITH"
created: 2005-05-02 11:02:00+0500
insurer: Organization/InsurerExample "MARYLAND CAPITAL INSURANCE COMPANY"
requestor: PractitionerRole/ReferralPractitionerRoleExample
outcome: complete
item
ItemRequestedServiceDate: 2005-05-02 --> 2005-06-02
ItemPreAuthIssueDate: 2005-05-02
ItemPreAuthPeriod: 2005-05-02 --> 2005-06-02
ItemAuthorizedProvider
url
providervalue: Practitioner/ReferralPractitionerExample " WATSON"
ItemAuthorizedDetail
url
productOrServiceCodevalue: Consultation (1365#3)
url
unitPricevalue: US$100.00 (USD)
url
quantityvalue: 1
itemSequence: 1
Adjudications
Extension Category Submitted Amount (Adjudication Value Codes#submitted)