Outbound response

Nurse review

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-1002",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional"
      }
    ]
  },
  "use": "preauthorization",
  "patient": {
    "display": "R. Smith (SYNTHETIC)"
  },
  "created": "2026-07-12T15:08:05+00:00",
  "outcome": "queued",
  "disposition": "Pended \u2014 clinical review",
  "item": [
    {
      "itemSequence": 1,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligible"
              }
            ]
          },
          "reason": {
            "text": "The chart does not currently support medical necessity for lumbar MRI. Symptom duration is only 3 weeks, below the 6-week threshold in [C4], and no conservative therapy trial has been completed per [C1]\u2014only same-day advice for rest and OTC ibuprofen was given, with no PT started. Because no red flag is documented ([C5] explicitly noted as absent), the conservative-therapy and duration requirements are not waived. Additionally, no neurological exam is documented ([C3]), and there is no evidence that imaging would alter management ([C6]); the request appears to be patient-driven rather than based on a failed conservative trial or radicular findings. Approval should be deferred pending completion of a guideline-concordant conservative therapy trial, a repeat visit documenting persistent or worsening symptoms, and a focused neurological exam, unless a red-flag condition emerges that would independently justify expedited imaging."
          }
        }
      ],
      "extension": [
        {
          "url": "https://threadmaze.example/review-action",
          "valueString": "pended"
        }
      ],
      "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 chart does not currently support medical necessity for lumbar MRI. Symptom duration is only 3 weeks, below the 6-week threshold in [C4], and no conservative therapy trial has been completed per [C1]\u2014only same-day advice for rest and OTC ibuprofen was given, with no PT started. Because no red flag is documented ([C5] explicitly noted as absent), the conservative-therapy and duration requirements are not waived. Additionally, no neurological exam is documented ([C3]), and there is no evidence that imaging would alter management ([C6]); the request appears to be patient-driven rather than based on a failed conservative trial or radicular findings. Approval should be deferred pending completion of a guideline-concordant conservative therapy trial, a repeat visit documenting persistent or worsening symptoms, and a focused neurological exam, unless a red-flag condition emerges that would independently justify expedited imaging."
    }
  ],
  "_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-1002*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*A4*AUTH-001002~  // decision: Pended
MSG*The chart does not currently support medical necessity for lumbar MRI. Symptom duration is only 3 weeks, below the 6-week threshold in [C4], and no conservative therapy trial has been completed per [C1]—only same-day advice for rest and OTC ibuprofen~  // cited clinical rationale
SE*9*0001~

🔒 Synthetic data only — not for clinical use.