Outbound response

{
  "resourceType": "ClaimResponse",
  "id": "claimresponse-CASE-1005",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional"
      }
    ]
  },
  "use": "preauthorization",
  "patient": {
    "display": "J. Doe (SYNTHETIC)"
  },
  "created": "2026-07-15T09:08:05+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 patient meets the core commercial-baseline criteria: an adequate conservative therapy trial [C1] (8 weeks PT, 6 weeks NSAIDs) with persistent, progressive symptoms despite treatment [C2], a documented focused neurological exam showing mild L5 motor and sensory deficits [C3], symptom duration of 10 weeks exceeding the 6-week threshold [C4], and clear expected impact on management, as the MRI will guide a choice between epidural steroid injection and surgical referral [C6]. No red-flag criterion is substantiated in the chart [C5]: cauda equina findings are explicitly negative and the motor deficit, while present, is not documented as progressive, so C1, C4, and C7 are not waived.\n\nBecause this plan requires a prior plain lumbar radiograph before advanced imaging is authorized, and no such radiograph or its result is documented anywhere in the chart [C7], the request cannot currently be approved. Authorization should be reconsidered once a plain X-ray of the lumbar spine has been obtained and its findings documented, or if the treating provider documents a red-flag finding (e.g., a clearly progressive motor deficit) that would waive C7."
          }
        }
      ],
      "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 patient meets the core commercial-baseline criteria: an adequate conservative therapy trial [C1] (8 weeks PT, 6 weeks NSAIDs) with persistent, progressive symptoms despite treatment [C2], a documented focused neurological exam showing mild L5 motor and sensory deficits [C3], symptom duration of 10 weeks exceeding the 6-week threshold [C4], and clear expected impact on management, as the MRI will guide a choice between epidural steroid injection and surgical referral [C6]. No red-flag criterion is substantiated in the chart [C5]: cauda equina findings are explicitly negative and the motor deficit, while present, is not documented as progressive, so C1, C4, and C7 are not waived.\n\nBecause this plan requires a prior plain lumbar radiograph before advanced imaging is authorized, and no such radiograph or its result is documented anywhere in the chart [C7], the request cannot currently be approved. Authorization should be reconsidered once a plain X-ray of the lumbar spine has been obtained and its findings documented, or if the treating provider documents a red-flag finding (e.g., a clearly progressive motor deficit) that would waive C7."
    }
  ],
  "_note": "SYNTHETIC \u2014 illustrative FHIR PAS ClaimResponse for a portfolio demo."
}

// SYNTHETIC X12 278 response — illustrative segments only, not a valid ISA/GS/ST envelope.
ST*278*0001*005010X217~
BHT*0007*11*CASE-1005*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-001005~  // decision: Pended
MSG*The patient meets the core commercial-baseline criteria: an adequate conservative therapy trial [C1] (8 weeks PT, 6 weeks NSAIDs) with persistent, progressive symptoms despite treatment [C2], a documented focused neurological exam showing mild L5 mot~  // cited clinical rationale
SE*9*0001~