ClaimResponse Example: claimresponse-example-unsolicited-preauth

Narrative

A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.

Example XML

<ClaimResponse xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/claimresponse.xsd">

    <id value="UR3503"/>

    <text>
        <status value="generated"/>
        <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>
    </text>

    <identifier>
        <system value="http://www.SocialBenefitsInc.com/fhir/ClaimResponse"/>
        <value value="UR3503"/>
    </identifier>

    <status value="active"/>

    <type>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="oral"/>
        </coding>
    </type>

    <use value="preauthorization"/> <!-- this is unsolicited therefore no reference to the preauthorization request exists -->

    <subject>
        <reference value="Patient/1"/>
    </subject>

    <created value="2014-08-16"/>

    <insurer>
        <identifier>
            <system value="http://www.jurisdiction.org/insurers"/>
            <value value="444123"/> <!-- Social Benefits Inc. -->
        </identifier>
    </insurer>

    <requestor>
        <reference value="Organization/1"/>
    </requestor>

    <outcome value="complete" />

    <disposition value="The enclosed services are authorized for your provision within 30 days of this notice."/>

    <preAuthRef value="18SS12345" />

    <payeeType>	<!-- advise that assignment of benefit is allowed -->
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
            <code value="provider"/>
        </coding>
    </payeeType>

    <!-- Authorization details -->

    <!-- Authorization to receive an exam and an Xray panel -->
    <addItem> <!-- Exam -->
        <itemSequence value="1"/>
        <productOrService>
            <coding>
                <system value="http://example.org/fhir/oralservicecodes"/>
                <code value="1101"/>
            </coding>
        </productOrService>
        <modifier>
            <coding>
                <system value="http://example.org/fhir/modifiers"/>
                <code value="x"/>
                <display value="None"/>
            </coding>
        </modifier>
        <net>
            <value value="250.00"/> <!-- net set to same value as the eligible amount. Providers will only be reimbursed to the net/eligible amount less the co-pay. -->
            <currency value="USD"/>
        </net>
        <noteNumber value="101"/>
        <adjudication>
            <category>
                <coding>
                    <code value="eligible"/>
                </coding>
            </category>
            <amount>
                <value value="250.00"/>
                <currency value="USD"/>
            </amount>
        </adjudication>

        <adjudication>
            <category>
                <coding>
                    <code value="copay"/>
                </coding>
            </category>
            <amount>
                <value value="10.00"/>
                <currency value="USD"/>
            </amount>
        </adjudication>

        <adjudication>
            <category>
                <coding>
                    <code value="eligpercent"/>
                </coding>
            </category>
            <quantity>
                <value value="100.00"/>
            </quantity>
        </adjudication>
        <adjudication>
            <category>
                <coding>
                    <code value="benefit"/>
                </coding>
            </category>
            <amount>
                <value value="240.00"/> <!-- insurer will pay up to this amount. -->
                <currency value="USD"/>
            </amount>
        </adjudication>

    </addItem>

    <addItem> <!-- Xray Panel -->
        <itemSequence value="1"/>
        <productOrService>
            <coding>
                <system value="http://example.org/fhir/oralservicecodes"/>
                <code value="2101"/>
                <display value="Radiograph, series (12)"/>
            </coding>
        </productOrService>
        <net>
            <value value="800.00"/>
            <currency value="USD"/>
        </net>
        <adjudication>
            <category>
                <coding>
                    <code value="eligible"/>
                </coding>
            </category>
            <amount>
                <value value="800.00"/>
                <currency value="USD"/>
            </amount>
        </adjudication>

        <adjudication>
            <category>
                <coding>
                    <code value="eligpercent"/>
                </coding>
            </category>
            <quantity>
                <value value="100.00"/>
            </quantity>
        </adjudication>
        <adjudication>
            <category>
                <coding>
                    <code value="benefit"/>
                </coding>
            </category>
            <amount>
                <value value="800.00"/>
                <currency value="USD"/>
            </amount>
        </adjudication>
    </addItem>

    <total>
        <category>
            <coding>
                <code value="submitted"/>
            </coding>
        </category>
        <amount>
            <value value="1050.00"/>
            <currency value="USD"/>
        </amount>
    </total>

    <total>
        <category>
            <coding>
                <code value="benefit"/>
            </coding>
        </category>
        <amount>
            <value value="1040.00"/>
            <currency value="USD"/>
        </amount>
    </total>

    <processNote>
        <number value="101"/>
        <type>
            <coding>
                <system value="http://hl7.org/fhir/note-type"/>
                <code value="print"/>
            </coding>
        </type>
        <text value="Please submit a Pre-Authorization request if a more extensive examination or urgent services are required."/>
        <language>
            <coding>
                <system value="urn:ietf:bcp:47" />
                <code value="en-CA" />
            </coding>
        </language>
    </processNote>

    <insurance>
        <sequence value="1"/>
        <focal value="true"/>
        <coverage>
            <reference value="Coverage/9876B1"/>
        </coverage>
    </insurance>
</ClaimResponse>