---
type: "example"
title: "ClaimResponse Example: claimresponse-example-unsolicited-preauth"
resource: "ClaimResponse"
example: "claimresponse-example-unsolicited-preauth"
---
# 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



```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>
```