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: Unsolicited Prior Authorization example - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "UnsolicitedReferralAuthorizationResponseExample",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource \"UnsolicitedReferralAuthorizationResponseExample\" </p></div><p><b>identifier</b>: id: 111099</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"http://example.org/new-payer/fhir/Patient/pat1\">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/full</a> \"New Health Plan\"</p><p><b>requestor</b>: <a href=\"http://example.org/someProvider/fhir/Organization/good-health-clinic\">http://example.org/someProvider/fhir/Organization/good-health-clinic</a></p><p><b>outcome</b>: complete</p><p><b>preAuthRef</b>: A1B2C3D4</p><blockquote><p><b>addItem</b></p><p><b>Authorized Date</b>: 2005-05-02 --&gt; 2005-06-02</p><p><b>Pre Authorized Issue Date</b>: 2005-05-02</p><p><b>Authorized Provider</b>: <a href=\"Practitioner-full.html\">Practitioner/full</a> \" BONE\"</p><p><b>Item Trace Number</b>: id: A1B2C3D4</p><p><b>itemSequence</b>: 1</p><p><b>productOrService</b>: Consultation <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#3)</span></p><p><b>location</b>: 11 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#11)</span></p><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td>*</td><td></td><td>Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</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" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-reviewAction",
              "extension" : [
                {
                  "url" : "number",
                  "valueString" : "AUTH0001"
                },
                {
                  "url" : "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-reviewActionCode",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://codesystem.x12.org/005010/306",
                        "code" : "A1",
                        "display" : "Certified in total"
                      }
                    ]
                  }
                }
              ]
            }
          ],
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          }
        }
      ]
    }
  ]
}