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>     <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

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