Outbound response

Auto-approved AUTH-001001

What the payer transmits back to the ordering provider — the decision, in the two formats CMS-0057-F expects.

FHIR PAS · ClaimResponse

The primary, real-shaped output (CMS-mandated by 2027).

{
  "resourceType": "ClaimResponse",
  "id": "claimresponse-CASE-1001",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional"
      }
    ]
  },
  "use": "preauthorization",
  "patient": {
    "display": "J. Doe (SYNTHETIC)"
  },
  "created": "2026-07-15T19:08:05+00:00",
  "outcome": "complete",
  "disposition": "Authorized",
  "preAuthRef": "AUTH-001001",
  "item": [
    {
      "itemSequence": 1,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligible"
              }
            ]
          },
          "reason": {
            "text": "The patient meets all standard (non-red-flag) criteria for lumbar MRI without contrast. Conservative therapy was appropriately trialed and exceeded the required duration [C1], with symptoms persisting and progressing despite this treatment [C2]. A focused neurological exam supports a right L5 radiculopathy with objective motor and sensory findings [C3], and symptoms have been present for 10 weeks, satisfying the duration requirement [C4]. Although no red-flag features are documented (C5 not met, so C1/C4 are not waived but are independently satisfied), the requesting provider clearly states the MRI results will guide the choice between epidural steroid injection and surgical referral, satisfying the management-impact criterion [C6]. No additional documentation is required for approval based on the current chart."
          }
        }
      ],
      "extension": [
        {
          "url": "https://threadmaze.example/review-action",
          "valueString": "approved"
        }
      ],
      "productOrService": {
        "coding": [
          {
            "system": "https://www.ama-assn.org/go/cpt",
            "code": "72148"
          }
        ],
        "text": "MRI lumbar spine without contrast (CPT 72148)"
      }
    }
  ],
  "processNote": [
    {
      "number": 1,
      "type": "display",
      "text": "The patient meets all standard (non-red-flag) criteria for lumbar MRI without contrast. Conservative therapy was appropriately trialed and exceeded the required duration [C1], with symptoms persisting and progressing despite this treatment [C2]. A focused neurological exam supports a right L5 radiculopathy with objective motor and sensory findings [C3], and symptoms have been present for 10 weeks, satisfying the duration requirement [C4]. Although no red-flag features are documented (C5 not met, so C1/C4 are not waived but are independently satisfied), the requesting provider clearly states the MRI results will guide the choice between epidural steroid injection and surgical referral, satisfying the management-impact criterion [C6]. No additional documentation is required for approval based on the current chart."
    }
  ],
  "_note": "SYNTHETIC \u2014 illustrative FHIR PAS ClaimResponse for a portfolio demo."
}

X12 278 · response segments

Illustrative EDI view — not a full ISA/GS envelope.

// SYNTHETIC X12 278 response — illustrative segments only, not a valid ISA/GS/ST envelope.
ST*278*0001*005010X217~
BHT*0007*11*CASE-1001*20260715~
HL*1**20*1~   // Utilization Management Organization (payer/TPA)
HL*2*1*21*1~  // Requester (ordering provider)
HL*3*2*22*0~  // Subscriber / member
UM*HS*I*72148~  // service reviewed
HCR*A1*AUTH-001001~  // decision: Certified in total
MSG*The patient meets all standard (non-red-flag) criteria for lumbar MRI without contrast. Conservative therapy was appropriately trialed and exceeded the required duration [C1], with symptoms persisting and progressing despite this treatment [C2]. A fo~  // cited clinical rationale
SE*9*0001~

🔒 Synthetic data only — not for clinical use.