{
  "resourceType" : "ClaimResponse",
  "id" : "ClaimResponse-predetermination-example-01",
  "meta" : {
    "profile" : ["https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse"]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse ClaimResponse-predetermination-example-01</b></p><a name=\"ClaimResponse-predetermination-example-01\"> </a><a name=\"hcClaimResponse-predetermination-example-01\"> </a><a name=\"ClaimResponse-predetermination-example-01-hi-IN\"> </a><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 737481003}\">Inpatient care management (procedure)</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href=\"Patient-example-01.html\">ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)</a></p><p><b>created</b>: 2023-12-12 15:32:26+0530</p><p><b>insurer</b>: <a href=\"Organization-example-02.html\">Organization XYZ Insurance Co. Ltd.</a></p><p><b>requestor</b>: <a href=\"Organization-example-03.html\">Organization XYZ Hospital Co. Ltd.</a></p><p><b>request</b>: <a href=\"Claim-Claim-predetermination-example-01.html\">Claim: identifier = 7612345; status = active; type = Inpatient care management (procedure); subType = Emergency Claim; use = predetermination; billablePeriod = 2025-03-07 11:01:00+0500 --&gt; 2025-04-07 11:01:00+0500; created = 2025-03-07 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</p><p><b>preAuthRef</b>: 123456</p><p><b>payeeType</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}\">Provider</span></p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><p><b>reason</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason covered}\">Product or Service requested is covered by the policy.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 2</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>40000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><p><b>reason</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason covered}\">Product or Service requested is covered by the policy.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>40000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 3</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><p><b>reason</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason covered}\">Product or Service requested is covered by the policy.</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>70000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>70000</td><td>Indian rupee</td></tr></table></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-example-01.html\">Coverage: identifier = https://xyzinsurance.in/policynumber/#235037120; status = active; type = PAY; subscriberId = ABC123456BI007; relationship = Self; period = (?) --&gt; 2026-03-17</a></td></tr></table></div>"
  },
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "737481003",
      "display" : "Inpatient care management (procedure)"
    }]
  },
  "use" : "predetermination",
  "patient" : {
    "reference" : "Patient/example-01"
  },
  "created" : "2023-12-12T15:32:26.605+05:30",
  "insurer" : {
    "reference" : "Organization/example-02"
  },
  "requestor" : {
    "reference" : "Organization/example-03"
  },
  "request" : {
    "reference" : "Claim/Claim-predetermination-example-01"
  },
  "outcome" : "complete",
  "preAuthRef" : "123456",
  "payeeType" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
      "code" : "provider"
    }]
  },
  "item" : [{
    "itemSequence" : 1,
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "submitted",
          "display" : "Submitted Amount"
        }]
      },
      "amount" : {
        "value" : 10000,
        "currency" : "INR"
      }
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "eligpercent",
          "display" : "Eligible %"
        }]
      },
      "reason" : {
        "coding" : [{
          "system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
          "code" : "covered",
          "display" : "Product or Service requested is covered by the policy."
        }]
      },
      "amount" : {
        "value" : 10000,
        "currency" : "INR"
      }
    }]
  },
  {
    "itemSequence" : 2,
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "submitted",
          "display" : "Submitted Amount"
        }]
      },
      "amount" : {
        "value" : 40000,
        "currency" : "INR"
      }
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "eligpercent",
          "display" : "Eligible %"
        }]
      },
      "reason" : {
        "coding" : [{
          "system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
          "code" : "covered",
          "display" : "Product or Service requested is covered by the policy."
        }]
      },
      "amount" : {
        "value" : 40000,
        "currency" : "INR"
      }
    }]
  },
  {
    "itemSequence" : 3,
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "submitted",
          "display" : "Submitted Amount"
        }]
      },
      "amount" : {
        "value" : 20000,
        "currency" : "INR"
      }
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "eligpercent",
          "display" : "Eligible %"
        }]
      },
      "reason" : {
        "coding" : [{
          "system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
          "code" : "covered",
          "display" : "Product or Service requested is covered by the policy."
        }]
      },
      "amount" : {
        "value" : 20000,
        "currency" : "INR"
      }
    }]
  }],
  "total" : [{
    "category" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
        "code" : "submitted",
        "display" : "Submitted Amount"
      }]
    },
    "amount" : {
      "value" : 70000,
      "currency" : "INR"
    }
  },
  {
    "category" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
        "code" : "eligpercent",
        "display" : "Eligible %"
      }]
    },
    "amount" : {
      "value" : 70000,
      "currency" : "INR"
    }
  }],
  "insurance" : [{
    "sequence" : 1,
    "focal" : true,
    "coverage" : {
      "reference" : "Coverage/example-01"
    }
  }]
}