{
  "resourceType" : "ClaimResponse",
  "id" : "PractitionerRequestorPendingResponseExample",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"]
  },
  "language" : "en",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse PractitionerRequestorPendingResponseExample</b></p><a name=\"PractitionerRequestorPendingResponseExample\"> </a><a name=\"hcPractitionerRequestorPendingResponseExample\"> </a><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\">Language: en</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claimresponse.html\">PAS Claim Response</a></p></div><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=\"Patient-SubscriberExample.html\">JOE SMITH  Male, DoB Unknown ( http://example.org/MIN#12345678901)</a></p><p><b>created</b>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>requestor</b>: <a href=\"PractitionerRole-ReferralPractitionerRoleExample.html\">PractitionerRole: telecom = ph: 4029993456</a></p><p><b>request</b>: <a href=\"Claim-ReferralAuthorizationExample.html\">Claim: extension = Urgent,; identifier = urn:trnorg:9012345678#111099; status = active; type = Professional; use = preauthorization; created = 2005-05-02 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Complete</p><blockquote><p><b>item</b></p><p><b>Administration Reference Number</b>: PEND0001</p><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><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" : "Patient/SubscriberExample"
  },
  "created" : "2005-05-02T11:02:00+05:00",
  "insurer" : {
    "reference" : "Organization/InsurerExample"
  },
  "requestor" : {
    "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
  },
  "request" : {
    "reference" : "Claim/ReferralAuthorizationExample"
  },
  "outcome" : "complete",
  "item" : [{
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
      "valueString" : "PEND0001"
    }],
    "itemSequence" : 1,
    "adjudication" : [{
      "extension" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
          "valueCodeableConcept" : {
            "coding" : [{
              "system" : "https://codesystem.x12.org/005010/306",
              "code" : "A4",
              "display" : "Pending"
            }]
          }
        }],
        "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
      }],
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "submitted"
        }]
      }
    }]
  }]
}