Unsolicited Pre-Authorization for social Dental Services (id = "UR3503")

<?xml version="1.0" encoding="UTF-8"?>

<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"/> 
  <!--   this is unsolicited therefore no reference to the preauthorization request exists
     -->
  <patient> 
    <reference value="Patient/1"/> 
  </patient> 
  <created value="2014-08-16"/> 
  <insurer> 
    <!--   Social Benefits Inc.   -->
    <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> 
    <!--   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>