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: Unsolicited Prior Authorization example - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "UnsolicitedReferralAuthorizationResponseExample",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-claimresponse"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse UnsolicitedReferralAuthorizationResponseExample</b></p><a name=\"UnsolicitedReferralAuthorizationResponseExample\"> </a><a name=\"hcUnsolicitedReferralAuthorizationResponseExample\"> </a><a name=\"UnsolicitedReferralAuthorizationResponseExample-en-US\"> </a><p><b>identifier</b>: <code>http://example.org/PATIENT_EVENT_TRACE_NUMBER</code>/111099</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}\">Professional</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.3.1.1@3.1.1&amp;canonical=http://example.org/new-payer/fhir/Patient/pat1\">??</a></p><p><b>created</b>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href=\"Organization-full.html\">Organization New Health Plan</a></p><p><b>requestor</b>: <a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.3.1.1@3.1.1&amp;canonical=http://example.org/someProvider/fhir/Organization/good-health-clinic\">??</a></p><p><b>outcome</b>: Processing Complete</p><p><b>preAuthRef</b>: A1B2C3D4</p><blockquote><p><b>addItem</b></p><p><b>itemSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://codesystem.x12.org/005010/1365 3}\">Consultation</span></p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}\">11</span></p><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</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" : "http://example.org/new-payer/fhir/Patient/pat1"
  },
  "created" : "2005-05-02T11:02:00+05:00",
  "insurer" : {
    🔗 "reference" : "Organization/full"
  },
  "requestor" : {
    "reference" : "http://example.org/someProvider/fhir/Organization/good-health-clinic"
  },
  "outcome" : "complete",
  "preAuthRef" : "A1B2C3D4",
  "addItem" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-itemAuthorizedDate",
          "valuePeriod" : {
            "start" : "2005-05-02",
            "end" : "2005-06-02"
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-itemPreAuthIssueDate",
          "valueDate" : "2005-05-02"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-itemAuthorizedProvider",
          "valueReference" : {
            🔗 "reference" : "Practitioner/full"
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-itemTraceNumber",
          "valueIdentifier" : {
            "system" : "http://example.org/new-payer/fhir/NamingSystem/auth-numbers",
            "value" : "A1B2C3D4"
          }
        }
      ],
      "itemSequence" : [
        1
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://codesystem.x12.org/005010/1365",
            "code" : "3",
            "display" : "Consultation"
          }
        ]
      },
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
            "code" : "11"
          }
        ]
      },
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          }
        }
      ]
    }
  ]
}