Claimresponse-example-unsolicited-preauth.json

Unsolicited Pre-Authorization for social Dental Services

{
  "resourceType": "ClaimResponse",
  "id": "UR3503",
  "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"
      }
    }
  ]
}