<ClaimResponse xmlns="http://hl7.org/fhir"><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"/><subject><reference value="Patient/1"/></subject><created value="2014-08-16"/><insurer><identifier><system value="http://www.jurisdiction.org/insurers"/><value value="444123"/></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><coding><system value="http://terminology.hl7.org/CodeSystem/payeetype"/><code value="provider"/></coding></payeeType><addItem><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"/><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"/><currency value="USD"/></amount></adjudication></addItem><addItem><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>