Outbound response
Auto-approved AUTH-001003What 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-1003",
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"use": "preauthorization",
"patient": {
"display": "M. Lee (SYNTHETIC)"
},
"created": "2026-07-16T09:08:05+00:00",
"outcome": "complete",
"disposition": "Authorized",
"preAuthRef": "AUTH-001003",
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"reason": {
"text": "This is an urgent request supported by a clear red-flag presentation: the chart documents saddle anesthesia, bilateral lower extremity weakness, diminished reflexes, and new urinary retention with elevated post-void residual, with explicit clinical concern for cauda equina syndrome [C5]. Under policy, this red flag independently justifies imaging and waives the conservative-therapy and symptom-duration requirements [C1, C4], consistent with the acute 2-day symptom course documented. A focused neurological exam (motor, sensory, reflexes) is documented and supports a neurological/radicular process [C3], and neurosurgery has been consulted with the MRI intended to evaluate for compression, indicating the result will directly inform surgical management [C6]. Given the red-flag status, this case should be expedited per the policy's urgent (72-hour) turnaround and should not be delayed for standard prior authorization."
}
}
],
"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": "This is an urgent request supported by a clear red-flag presentation: the chart documents saddle anesthesia, bilateral lower extremity weakness, diminished reflexes, and new urinary retention with elevated post-void residual, with explicit clinical concern for cauda equina syndrome [C5]. Under policy, this red flag independently justifies imaging and waives the conservative-therapy and symptom-duration requirements [C1, C4], consistent with the acute 2-day symptom course documented. A focused neurological exam (motor, sensory, reflexes) is documented and supports a neurological/radicular process [C3], and neurosurgery has been consulted with the MRI intended to evaluate for compression, indicating the result will directly inform surgical management [C6]. Given the red-flag status, this case should be expedited per the policy's urgent (72-hour) turnaround and should not be delayed for standard prior authorization."
}
],
"_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-1003*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-001003~ // decision: Certified in total MSG*This is an urgent request supported by a clear red-flag presentation: the chart documents saddle anesthesia, bilateral lower extremity weakness, diminished reflexes, and new urinary retention with elevated post-void residual, with explicit clinical c~ // cited clinical rationale SE*9*0001~
🔒 Synthetic data only — not for clinical use.