{
  "resourceType" : "Parameters",
  "id" : "PASClaimInquiryOperationResponseExample",
  "language" : "en",
  "parameter" : [{
    "name" : "responseBundle",
    "resource" : {
      "resourceType" : "Bundle",
      "id" : "PASClaimInquiryResponseBundleExample",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-response-bundle"]
      },
      "language" : "en",
      "identifier" : {
        "system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER",
        "value" : "5269367"
      },
      "type" : "collection",
      "timestamp" : "2005-05-02T11:01:00+05:00",
      "entry" : [{
        "fullUrl" : "http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample",
        "resource" : {
          "resourceType" : "ClaimResponse",
          "id" : "PASClaimInquiryResponseExample",
          "meta" : {
            "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse"]
          },
          "language" : "en",
          "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" : "2019-07-20T11:01:00+05:00",
          "insurer" : {
            "reference" : "Organization/InsurerExample"
          },
          "request" : {
            "reference" : "Claim/ReferralAuthorizationExample"
          },
          "outcome" : "complete",
          "item" : [{
            "extension" : [{
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate",
              "valuePeriod" : {
                "start" : "2005-05-02",
                "end" : "2005-06-02"
              }
            }],
            "itemSequence" : 1,
            "adjudication" : [{
              "extension" : [{
                "extension" : [{
                  "url" : "number",
                  "valueString" : "AUTH0001"
                },
                {
                  "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
                  "valueCodeableConcept" : {
                    "coding" : [{
                      "system" : "https://codesystem.x12.org/005010/306",
                      "code" : "A1",
                      "display" : "Certified in total"
                    }]
                  }
                }],
                "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
              }],
              "category" : {
                "coding" : [{
                  "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                  "code" : "submitted"
                }]
              }
            }]
          }],
          "insurance" : [{
            "sequence" : 1,
            "focal" : true,
            "coverage" : {
              "reference" : "Coverage/InsuranceExample"
            }
          }]
        }
      },
      {
        "fullUrl" : "http://example.org/fhir/Organization/UMOExample",
        "resource" : {
          "resourceType" : "Organization",
          "id" : "UMOExample",
          "meta" : {
            "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"]
          },
          "language" : "en",
          "identifier" : [{
            "system" : "http://hl7.org/fhir/sid/us-npi",
            "value" : "8189991234"
          }],
          "active" : true,
          "type" : [{
            "coding" : [{
              "system" : "https://codesystem.x12.org/005010/98",
              "code" : "X3"
            }]
          }],
          "name" : "DR. JOE SMITH CORPORATION",
          "address" : [{
            "line" : ["111 1ST STREET"],
            "city" : "SAN DIEGO",
            "state" : "CA",
            "postalCode" : "92101",
            "country" : "US"
          }]
        }
      },
      {
        "fullUrl" : "http://example.org/fhir/Organization/InsurerExample",
        "resource" : {
          "resourceType" : "Organization",
          "id" : "InsurerExample",
          "meta" : {
            "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"]
          },
          "language" : "en",
          "identifier" : [{
            "system" : "http://hl7.org/fhir/sid/us-npi",
            "value" : "1234567893"
          }],
          "active" : true,
          "type" : [{
            "coding" : [{
              "system" : "https://codesystem.x12.org/005010/98",
              "code" : "PR"
            }]
          }],
          "name" : "MARYLAND CAPITAL INSURANCE COMPANY"
        }
      },
      {
        "fullUrl" : "http://example.org/fhir/Coverage/InsuranceExample",
        "resource" : {
          "resourceType" : "Coverage",
          "id" : "InsuranceExample",
          "meta" : {
            "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"]
          },
          "language" : "en",
          "identifier" : [{
            "type" : {
              "coding" : [{
                "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
                "code" : "MB"
              }]
            }
          }],
          "status" : "active",
          "subscriberId" : "1122334455",
          "beneficiary" : {
            "reference" : "Patient/SubscriberExample"
          },
          "relationship" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
              "code" : "self"
            },
            {
              "system" : "https://codesystem.x12.org/005010/1069",
              "code" : "18"
            }]
          },
          "payor" : [{
            "reference" : "Organization/InsurerExample"
          }]
        }
      },
      {
        "fullUrl" : "http://example.org/fhir/Patient/SubscriberExample",
        "resource" : {
          "resourceType" : "Patient",
          "id" : "SubscriberExample",
          "meta" : {
            "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"]
          },
          "language" : "en",
          "extension" : [{
            "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus",
            "valueCodeableConcept" : {
              "coding" : [{
                "system" : "https://codesystem.x12.org/005010/584",
                "code" : "RU"
              }]
            }
          }],
          "identifier" : [{
            "system" : "http://example.org/MIN",
            "value" : "12345678901"
          }],
          "name" : [{
            "family" : "SMITH",
            "given" : ["JOE"]
          }],
          "gender" : "male"
        }
      },
      {
        "fullUrl" : "http://example.org/fhir/Claim/ReferralAuthorizationExample",
        "resource" : {
          "resourceType" : "Claim",
          "id" : "ReferralAuthorizationExample",
          "meta" : {
            "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"]
          },
          "language" : "en",
          "extension" : [{
            "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode",
            "valueCodeableConcept" : {
              "coding" : [{
                "system" : "https://codesystem.x12.org/005010/1338",
                "code" : "U",
                "display" : "Urgent"
              }]
            }
          },
          {
            "extension" : [{
              "url" : "applicationSenderCode",
              "valueString" : "PROVIDERAPP"
            },
            {
              "url" : "applicationReceiverCode",
              "valueString" : "PAYERAPP"
            },
            {
              "url" : "interchangeSenderID",
              "valueString" : "PROVIDERID"
            },
            {
              "url" : "interchangeReceiverID",
              "valueString" : "PAYERID"
            }],
            "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers"
          }],
          "identifier" : [{
            "extension" : [{
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction",
              "valueCodeableConcept" : {
                "coding" : [{
                  "system" : "https://www.usps.com/",
                  "code" : "MA"
                }]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment",
              "valueString" : "223412"
            }],
            "system" : "urn:trnorg:9012345678",
            "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" : "2005-05-02T11:01:00+05:00",
          "insurer" : {
            "reference" : "Organization/InsurerExample"
          },
          "provider" : {
            "reference" : "Organization/UMOExample"
          },
          "priority" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
              "code" : "normal"
            }]
          },
          "careTeam" : [{
            "extension" : [{
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope",
              "valueBoolean" : true
            }],
            "sequence" : 1,
            "provider" : {
              "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
            }
          }],
          "supportingInfo" : [{
            "extension" : [{
              "extension" : [{
                "url" : "reportTypeCode",
                "valueCodeableConcept" : {
                  "coding" : [{
                    "system" : "https://codesystem.x12.org/005010/755",
                    "code" : "PY",
                    "display" : "Physician's Report"
                  }]
                }
              },
              {
                "url" : "transmissionMethod",
                "valueCodeableConcept" : {
                  "coding" : [{
                    "system" : "https://codesystem.x12.org/005010/756",
                    "code" : "EL",
                    "display" : "Electronically Only"
                  }]
                }
              },
              {
                "url" : "controlNumber",
                "valueString" : "111222"
              },
              {
                "url" : "description",
                "valueString" : "A procedure note included to provide details of what has been tried before the referral."
              }],
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation"
            }],
            "sequence" : 1,
            "category" : {
              "coding" : [{
                "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
                "code" : "additionalInformation"
              }]
            },
            "valueReference" : {
              "reference" : "DocumentReference/DocumentReferenceExample"
            }
          }],
          "diagnosis" : [{
            "extension" : [{
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate",
              "valueDate" : "2021-05-10"
            }],
            "sequence" : 1,
            "diagnosisCodeableConcept" : {
              "coding" : [{
                "system" : "http://hl7.org/fhir/sid/icd-10-cm",
                "code" : "G89.4"
              }]
            }
          }],
          "insurance" : [{
            "sequence" : 1,
            "focal" : true,
            "coverage" : {
              "reference" : "Coverage/InsuranceExample"
            }
          }],
          "item" : [{
            "extension" : [{
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
              "valueCodeableConcept" : {
                "coding" : [{
                  "system" : "https://codesystem.x12.org/005010/1525",
                  "code" : "SC",
                  "display" : "Specialty Care Review"
                }]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
              "valueCodeableConcept" : {
                "coding" : [{
                  "system" : "https://codesystem.x12.org/005010/1322",
                  "code" : "I",
                  "display" : "Initial"
                }]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
              "valueIdentifier" : {
                "system" : "http://example.org/ITEM_TRACE_NUMBER",
                "value" : "1122334"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber",
              "valueString" : "1122445"
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
              "valueString" : "9988311"
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
              "valueReference" : {
                "reference" : "ServiceRequest/ReferralRequestExample"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator",
              "valueBoolean" : false
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus",
              "valueCodeableConcept" : {
                "coding" : [{
                  "system" : "https://codesystem.x12.org/005010/1345",
                  "code" : "2",
                  "display" : "Newly Admitted"
                }]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare",
              "valueCodeableConcept" : {
                "coding" : [{
                  "system" : "https://codesystem.x12.org/005010/1337",
                  "code" : "2",
                  "display" : "Intermediate Care Facility (ICF)"
                }]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit",
              "valueDecimal" : 100
            }],
            "sequence" : 1,
            "careTeamSequence" : [1],
            "diagnosisSequence" : [1],
            "category" : {
              "coding" : [{
                "system" : "https://codesystem.x12.org/005010/1365",
                "code" : "3",
                "display" : "Consultation"
              }]
            },
            "productOrService" : {
              "coding" : [{
                "system" : "https://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"
              }]
            }
          }]
        }
      }]
    }
  }]
}