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"
        }]
      },
      "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"
    }
  }]
}