Receive and respond to preauthorization requests

Last updated: Apr 30, 2024
PAYER
PRODUCT OWNER

You can use this API action to process and respond to preauthorization requests. To kick off your workflow, your connection must submit a preauthorization request.

Use cases

This API action may be a good fit for your organization if you perform any of these use cases:

  • Approve or decline preauthorization requests.
  • Streamline or digitize your process for receiving preauthorization requests.

Check out our case study for more details about the problems you can solve with this API action. 

Supported systems

You can use this API action with a query-based API that can also exchange X12. Your responses to preauthorization requests can be either synchronous or asynchronous, depending on your own system’s capabilities.

Things you need to know

Action steps

Respond to a medication preauthorization request

This step requires that you support receiving Claim$submit-preauthorization and Claim$attach from your connection. You can decide what that processing looks like when you're ready to respond. Refer to these schemas for more details:

In the response, you must include whether your connection's request is accepted, pending, or declined.

ClaimResponse/$respond
Payload
json
1
{
2
"id": "RedoxClaimResponseBundleComprehensiveExample",
3
"type": "collection",
4
"entry": [
5
{
6
"resource": {
7
"id": "RedoxPAClaimResponseExample",
8
"use": "preauthorization",
9
"item": [
10
{
11
"extension": [
12
{
13
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
14
"valueString": "REF456"
15
},
16
{
17
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",
18
"valueDate": "2021-08-23"
19
},
20
{
21
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",
22
"valuePeriod": {
23
"end": "2021-09-23",
24
"start": "2021-08-23"
25
}
26
},
27
{
28
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
29
"valueIdentifier": {
30
"value": "23462346"
31
}
32
},
33
{
34
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail",
35
"extension": [
36
{
37
"url": "productOrServiceCode",
38
"valueCodeableConcept": {
39
"text": "Right heart catheterization",
40
"coding": [
41
{
42
"code": "93451",
43
"system": "http://www.ama-assn.org/go/cpt"
44
}
45
]
46
}
47
},
48
{
49
"url": "quantity",
50
"valueQuantity": {
51
"value": 1
52
}
53
},
54
{
55
"url": "unitPrice",
56
"valueMoney": {
57
"value": 4966,
58
"currency": "USD"
59
}
60
}
61
]
62
}
63
],
64
"adjudication": [
65
{
66
"category": {
67
"coding": [
68
{
69
"code": "submitted",
70
"system": "http://terminology.hl7.org/CodeSystem/adjudication"
71
}
72
]
73
},
74
"extension": [
75
{
76
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction",
77
"extension": [
78
{
79
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
80
"valueCodeableConcept": {
81
"coding": [
82
{
83
"code": "A1",
84
"system": "https://codesystem.x12.org/005010/306",
85
"display": "Certified in total"
86
}
87
]
88
}
89
},
90
{
91
"url": "number",
92
"valueString": "AUTH1001"
93
}
94
]
95
}
96
]
97
}
98
],
99
"itemSequence": 1
100
}
101
],
102
"type": {
103
"coding": [
104
{
105
"code": "professional",
106
"system": "http://terminology.hl7.org/CodeSystem/claim-type"
107
}
108
]
109
},
110
"status": "active",
111
"created": "2021-08-23T16:35:54.648Z",
112
"insurer": {
113
"reference": "Organization/RedoxPAInsurerOrganizationExample"
114
},
115
"outcome": "complete",
116
"patient": {
117
"reference": "Patient/RedoxPABeneficiaryExample"
118
},
119
"request": {
120
"reference": "Claim/RedoxPAServiceClaimExample",
121
"identifier": {
122
"type": {
123
"coding": [
124
{
125
"code": "ClaimID"
126
}
127
]
128
},
129
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
130
}
131
},
132
"requestor": {
133
"reference": "Organization/RedoxPARequestorOrganizationExample"
134
},
135
"processNote": [
136
{
137
"text": "Covered under extended benefits"
138
}
139
],
140
"resourceType": "ClaimResponse"
141
}
142
},
143
{
144
"resource": {
145
"id": "RedoxPABeneficiaryExample",
146
"name": [
147
{
148
"given": [
149
"Timothy",
150
"Paul"
151
],
152
"family": "Bixby"
153
}
154
],
155
"gender": "male",
156
"birthDate": "2008-01-06",
157
"identifier": [
158
{
159
"value": "M23462346",
160
"system": "urn:redox:MRN"
161
}
162
],
163
"resourceType": "Patient"
164
}
165
},
166
{
167
"resource": {
168
"id": "RedoxPACoverageWithRelatedSubscriberExample",
169
"class": [
170
{
171
"type": {
172
"coding": [
173
{
174
"code": "group",
175
"system": "http://terminology.hl7.org/CodeSystem/coverage-class"
176
}
177
]
178
},
179
"value": "GRP2245"
180
}
181
],
182
"payor": [
183
{
184
"reference": "Organization/RedoxPAInsurerOrganizationExample"
185
}
186
],
187
"status": "active",
188
"subscriber": {
189
"reference": "RelatedPerson/RedoxPASubscriberExample"
190
},
191
"beneficiary": {
192
"reference": "Patient/RedoxPABeneficiaryExample"
193
},
194
"resourceType": "Coverage",
195
"subscriberId": "M2346623"
196
}
197
},
198
{
199
"resource": {
200
"id": "RedoxPARequestorOrganizationExample",
201
"name": "Good Health Clinics",
202
"active": true,
203
"address": [
204
{
205
"city": "Madison",
206
"line": [
207
"123 Main St."
208
],
209
"state": "WI",
210
"country": "USA",
211
"district": "Dane",
212
"postalCode": "53703"
213
}
214
],
215
"resourceType": "Organization"
216
}
217
},
218
{
219
"resource": {
220
"id": "RedoxPAInsurerOrganizationExample",
221
"name": "Aetna",
222
"active": true,
223
"address": [
224
{
225
"city": "Lexington",
226
"line": [
227
"PO Box 14080"
228
],
229
"state": "KY",
230
"country": "USA",
231
"district": "Fayette",
232
"postalCode": "40512-4079"
233
}
234
],
235
"resourceType": "Organization"
236
}
237
},
238
{
239
"resource": {
240
"id": "RedoxPAPractitionerRoleExamplePat",
241
"location": [
242
{
243
"display": "1st Street Family Clinic"
244
}
245
],
246
"specialty": [
247
{
248
"coding": [
249
{
250
"code": "394579002",
251
"system": "http://snomed.info/sct",
252
"display": "Cardiology"
253
}
254
]
255
}
256
],
257
"organization": {
258
"reference": "Organization/RedoxPARequestorOrganizationExample"
259
},
260
"practitioner": {
261
"reference": "Practitioner/RedoxPAPractitionerExamplePat"
262
},
263
"resourceType": "PractitionerRole"
264
}
265
},
266
{
267
"resource": {
268
"id": "RedoxPAPractitionerExamplePat",
269
"name": [
270
{
271
"given": [
272
"Pat"
273
],
274
"family": "Granite"
275
}
276
],
277
"address": [
278
{
279
"city": "Madison",
280
"line": [
281
"123 Main St."
282
],
283
"state": "WI",
284
"country": "USA",
285
"district": "Dane",
286
"postalCode": "53703"
287
}
288
],
289
"telecom": [
290
{
291
"value": "+16085551234"
292
}
293
],
294
"identifier": [
295
{
296
"value": "4356789876",
297
"system": "http://hl7.org/fhir/sid/us-npi"
298
}
299
],
300
"resourceType": "Practitioner"
301
}
302
},
303
{
304
"resource": {
305
"id": "RedoxPASubscriberExample",
306
"name": [
307
{
308
"given": [
309
"Barbara"
310
],
311
"family": "Bixby"
312
}
313
],
314
"patient": {
315
"reference": "RedoxPABeneficiary"
316
},
317
"relationship": [
318
{
319
"text": "Mother"
320
}
321
],
322
"resourceType": "RelatedPerson"
323
}
324
},
325
{
326
"resource": {
327
"id": "RedoxPAServiceClaimExample",
328
"use": "preauthorization",
329
"item": [
330
{
331
"sequence": 1,
332
"extension": [
333
{
334
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
335
"valueReference": {
336
"reference": "ServiceRequest/RedoxPAServiceRequestExample"
337
}
338
},
339
{
340
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
341
"valueIdentifier": {
342
"value": "23462346"
343
}
344
}
345
],
346
"productOrService": {
347
"text": "Coronary angiography with right heart catheterization",
348
"coding": [
349
{
350
"code": "93456",
351
"system": "http://www.ama-assn.org/go/cpt"
352
}
353
]
354
}
355
}
356
],
357
"type": {
358
"coding": [
359
{
360
"code": "professional",
361
"system": "http://terminology.hl7.org/CodeSystem/claim-type"
362
}
363
]
364
},
365
"status": "active",
366
"created": "2021-09-02T18:44:13.307Z",
367
"enterer": {
368
"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"
369
},
370
"insurer": {
371
"reference": "Organization/RedoxPAInsurerOrganizationExample"
372
},
373
"patient": {
374
"reference": "Patient/RedoxPABeneficiaryExample"
375
},
376
"priority": {
377
"coding": [
378
{
379
"code": "normal",
380
"system": "http://terminology.hl7.org/CodeSystem/processpriority"
381
}
382
]
383
},
384
"provider": {
385
"reference": "Organization/RedoxPARequestorOrganizationExample"
386
},
387
"diagnosis": [
388
{
389
"sequence": 1,
390
"diagnosisCodeableConcept": {
391
"coding": [
392
{
393
"code": "I42.9",
394
"system": "http://hl7.org/fhir/sid/icd-10-cm",
395
"display": "Cardiomyopathy, unspecified"
396
}
397
]
398
}
399
}
400
],
401
"insurance": [
402
{
403
"focal": true,
404
"coverage": {
405
"reference": "Coverage/RedoxPACoverageExample"
406
},
407
"sequence": 1
408
}
409
],
410
"identifier": [
411
{
412
"type": {
413
"coding": [
414
{
415
"code": "ClaimID"
416
}
417
]
418
},
419
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
420
}
421
],
422
"resourceType": "Claim",
423
"supportingInfo": [
424
{
425
"category": {
426
"coding": [
427
{
428
"code": "additionalInformation",
429
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
430
"display": "Send additional paperwork or supporting information is sent for the request."
431
}
432
]
433
},
434
"sequence": 1,
435
"valueReference": {
436
"reference": "DocumentReference/RedoxPADocumentReferenceExample"
437
}
438
},
439
{
440
"category": {
441
"coding": [
442
{
443
"code": "freeFormMessage",
444
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
445
"display": "Written Confirmation."
446
}
447
]
448
},
449
"sequence": 2,
450
"valueString": "1"
451
}
452
]
453
}
454
}
455
],
456
"timestamp": "2021-10-21T19:09:02.452Z",
457
"identifier": {
458
"value": "urn:uuid:59f129cf-2eca-4965-88f2-452558af1934",
459
"system": "urn:ietf:rfc:3986"
460
},
461
"resourceType": "Bundle"
462
}

Respond to a service preauthorization request

This action step requires that you support receiving Claim$submit-preauthorization and Claim$attach from your connection. You can decide what that processing looks like when you're ready to respond. Refer to these schemas for more details:

In the response, you must include whether your connection's request is accepted, pending, or declined.

ClaimResponse/$respond
Payload
json
1
{
2
"id": "RedoxClaimResponseBundleComprehensiveExample",
3
"type": "collection",
4
"entry": [
5
{
6
"resource": {
7
"id": "RedoxPAClaimResponseExample",
8
"use": "preauthorization",
9
"item": [
10
{
11
"extension": [
12
{
13
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
14
"valueString": "REF456"
15
},
16
{
17
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",
18
"valueDate": "2021-08-23"
19
},
20
{
21
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",
22
"valuePeriod": {
23
"end": "2021-09-23",
24
"start": "2021-08-23"
25
}
26
},
27
{
28
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
29
"valueIdentifier": {
30
"value": "23462346"
31
}
32
},
33
{
34
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail",
35
"extension": [
36
{
37
"url": "productOrServiceCode",
38
"valueCodeableConcept": {
39
"text": "Right heart catheterization",
40
"coding": [
41
{
42
"code": "93451",
43
"system": "http://www.ama-assn.org/go/cpt"
44
}
45
]
46
}
47
},
48
{
49
"url": "quantity",
50
"valueQuantity": {
51
"value": 1
52
}
53
},
54
{
55
"url": "unitPrice",
56
"valueMoney": {
57
"value": 4966,
58
"currency": "USD"
59
}
60
}
61
]
62
}
63
],
64
"adjudication": [
65
{
66
"category": {
67
"coding": [
68
{
69
"code": "submitted",
70
"system": "http://terminology.hl7.org/CodeSystem/adjudication"
71
}
72
]
73
},
74
"extension": [
75
{
76
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction",
77
"extension": [
78
{
79
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
80
"valueCodeableConcept": {
81
"coding": [
82
{
83
"code": "A1",
84
"system": "https://codesystem.x12.org/005010/306",
85
"display": "Certified in total"
86
}
87
]
88
}
89
},
90
{
91
"url": "number",
92
"valueString": "AUTH1001"
93
}
94
]
95
}
96
]
97
}
98
],
99
"itemSequence": 1
100
}
101
],
102
"type": {
103
"coding": [
104
{
105
"code": "professional",
106
"system": "http://terminology.hl7.org/CodeSystem/claim-type"
107
}
108
]
109
},
110
"status": "active",
111
"created": "2021-08-23T16:35:54.648Z",
112
"insurer": {
113
"reference": "Organization/RedoxPAInsurerOrganizationExample"
114
},
115
"outcome": "complete",
116
"patient": {
117
"reference": "Patient/RedoxPABeneficiaryExample"
118
},
119
"request": {
120
"reference": "Claim/RedoxPAServiceClaimExample",
121
"identifier": {
122
"type": {
123
"coding": [
124
{
125
"code": "ClaimID"
126
}
127
]
128
},
129
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
130
}
131
},
132
"requestor": {
133
"reference": "Organization/RedoxPARequestorOrganizationExample"
134
},
135
"processNote": [
136
{
137
"text": "Covered under extended benefits"
138
}
139
],
140
"resourceType": "ClaimResponse"
141
}
142
},
143
{
144
"resource": {
145
"id": "RedoxPABeneficiaryExample",
146
"name": [
147
{
148
"given": [
149
"Timothy",
150
"Paul"
151
],
152
"family": "Bixby"
153
}
154
],
155
"gender": "male",
156
"birthDate": "2008-01-06",
157
"identifier": [
158
{
159
"value": "M23462346",
160
"system": "urn:redox:MRN"
161
}
162
],
163
"resourceType": "Patient"
164
}
165
},
166
{
167
"resource": {
168
"id": "RedoxPACoverageWithRelatedSubscriberExample",
169
"class": [
170
{
171
"type": {
172
"coding": [
173
{
174
"code": "group",
175
"system": "http://terminology.hl7.org/CodeSystem/coverage-class"
176
}
177
]
178
},
179
"value": "GRP2245"
180
}
181
],
182
"payor": [
183
{
184
"reference": "Organization/RedoxPAInsurerOrganizationExample"
185
}
186
],
187
"status": "active",
188
"subscriber": {
189
"reference": "RelatedPerson/RedoxPASubscriberExample"
190
},
191
"beneficiary": {
192
"reference": "Patient/RedoxPABeneficiaryExample"
193
},
194
"resourceType": "Coverage",
195
"subscriberId": "M2346623"
196
}
197
},
198
{
199
"resource": {
200
"id": "RedoxPARequestorOrganizationExample",
201
"name": "Good Health Clinics",
202
"active": true,
203
"address": [
204
{
205
"city": "Madison",
206
"line": [
207
"123 Main St."
208
],
209
"state": "WI",
210
"country": "USA",
211
"district": "Dane",
212
"postalCode": "53703"
213
}
214
],
215
"resourceType": "Organization"
216
}
217
},
218
{
219
"resource": {
220
"id": "RedoxPAInsurerOrganizationExample",
221
"name": "Aetna",
222
"active": true,
223
"address": [
224
{
225
"city": "Lexington",
226
"line": [
227
"PO Box 14080"
228
],
229
"state": "KY",
230
"country": "USA",
231
"district": "Fayette",
232
"postalCode": "40512-4079"
233
}
234
],
235
"resourceType": "Organization"
236
}
237
},
238
{
239
"resource": {
240
"id": "RedoxPAPractitionerRoleExamplePat",
241
"location": [
242
{
243
"display": "1st Street Family Clinic"
244
}
245
],
246
"specialty": [
247
{
248
"coding": [
249
{
250
"code": "394579002",
251
"system": "http://snomed.info/sct",
252
"display": "Cardiology"
253
}
254
]
255
}
256
],
257
"organization": {
258
"reference": "Organization/RedoxPARequestorOrganizationExample"
259
},
260
"practitioner": {
261
"reference": "Practitioner/RedoxPAPractitionerExamplePat"
262
},
263
"resourceType": "PractitionerRole"
264
}
265
},
266
{
267
"resource": {
268
"id": "RedoxPAPractitionerExamplePat",
269
"name": [
270
{
271
"given": [
272
"Pat"
273
],
274
"family": "Granite"
275
}
276
],
277
"address": [
278
{
279
"city": "Madison",
280
"line": [
281
"123 Main St."
282
],
283
"state": "WI",
284
"country": "USA",
285
"district": "Dane",
286
"postalCode": "53703"
287
}
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],
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"telecom": [
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{
291
"value": "+16085551234"
292
}
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],
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"identifier": [
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{
296
"value": "4356789876",
297
"system": "http://hl7.org/fhir/sid/us-npi"
298
}
299
],
300
"resourceType": "Practitioner"
301
}
302
},
303
{
304
"resource": {
305
"id": "RedoxPASubscriberExample",
306
"name": [
307
{
308
"given": [
309
"Barbara"
310
],
311
"family": "Bixby"
312
}
313
],
314
"patient": {
315
"reference": "RedoxPABeneficiary"
316
},
317
"relationship": [
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{
319
"text": "Mother"
320
}
321
],
322
"resourceType": "RelatedPerson"
323
}
324
},
325
{
326
"resource": {
327
"id": "RedoxPAServiceClaimExample",
328
"use": "preauthorization",
329
"item": [
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{
331
"sequence": 1,
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"extension": [
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{
334
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
335
"valueReference": {
336
"reference": "ServiceRequest/RedoxPAServiceRequestExample"
337
}
338
},
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{
340
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
341
"valueIdentifier": {
342
"value": "23462346"
343
}
344
}
345
],
346
"productOrService": {
347
"text": "Coronary angiography with right heart catheterization",
348
"coding": [
349
{
350
"code": "93456",
351
"system": "http://www.ama-assn.org/go/cpt"
352
}
353
]
354
}
355
}
356
],
357
"type": {
358
"coding": [
359
{
360
"code": "professional",
361
"system": "http://terminology.hl7.org/CodeSystem/claim-type"
362
}
363
]
364
},
365
"status": "active",
366
"created": "2021-09-02T18:44:13.307Z",
367
"enterer": {
368
"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"
369
},
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"insurer": {
371
"reference": "Organization/RedoxPAInsurerOrganizationExample"
372
},
373
"patient": {
374
"reference": "Patient/RedoxPABeneficiaryExample"
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},
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"priority": {
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"coding": [
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{
379
"code": "normal",
380
"system": "http://terminology.hl7.org/CodeSystem/processpriority"
381
}
382
]
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},
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"provider": {
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"reference": "Organization/RedoxPARequestorOrganizationExample"
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},
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"diagnosis": [
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{
389
"sequence": 1,
390
"diagnosisCodeableConcept": {
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"coding": [
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{
393
"code": "I42.9",
394
"system": "http://hl7.org/fhir/sid/icd-10-cm",
395
"display": "Cardiomyopathy, unspecified"
396
}
397
]
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}
399
}
400
],
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"insurance": [
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{
403
"focal": true,
404
"coverage": {
405
"reference": "Coverage/RedoxPACoverageExample"
406
},
407
"sequence": 1
408
}
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],
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"identifier": [
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{
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"type": {
413
"coding": [
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{
415
"code": "ClaimID"
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}
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]
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},
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"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
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}
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],
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"resourceType": "Claim",
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"supportingInfo": [
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{
425
"category": {
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"coding": [
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{
428
"code": "additionalInformation",
429
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
430
"display": "Send additional paperwork or supporting information is sent for the request."
431
}
432
]
433
},
434
"sequence": 1,
435
"valueReference": {
436
"reference": "DocumentReference/RedoxPADocumentReferenceExample"
437
}
438
},
439
{
440
"category": {
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"coding": [
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{
443
"code": "freeFormMessage",
444
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
445
"display": "Written Confirmation."
446
}
447
]
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},
449
"sequence": 2,
450
"valueString": "1"
451
}
452
]
453
}
454
}
455
],
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"timestamp": "2021-10-21T19:09:02.452Z",
457
"identifier": {
458
"value": "urn:uuid:59f129cf-2eca-4965-88f2-452558af1934",
459
"system": "urn:ietf:rfc:3986"
460
},
461
"resourceType": "Bundle"
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}