hl7

{"resourceType":"ClaimResponse","id":"UR3503","text":{"status":"generated","div":"\u003cdiv xmlns\u003d\"http://www.w3.org/1999/xhtml\"\u003eA sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.\u003c/div\u003e"},"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"}]},"quantity":{"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"}]},"quantity":{"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":{"coding":[{"system":"http://hl7.org/fhir/note-type","code":"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"}]}}