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Source1

{
  "resourceType": "ClaimResponse",
  "id": "ErrorResponseExample",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
    ]
  },
  "language": "en",
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "extension": [
        {
          "url": "applicationSenderCode",
          "valueString": "PAYERAPP"
        },
        {
          "url": "applicationReceiverCode",
          "valueString": "PROVIDERAPP"
        },
        {
          "url": "interchangeSenderID",
          "valueString": "PAYERID"
        },
        {
          "url": "interchangeReceiverID",
          "valueString": "PROVIDERID"
        }
      ],
      "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers"
    }
  ],
  "identifier": [
    {
      "system": "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
      "value": "111099",
      "assigner": {
        "identifier": {
          "system": "http://example.org/USER_ASSIGNED",
          "value": "9012345678"
        }
      }
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional"
      }
    ]
  },
  "use": "preauthorization",
  "patient": {
    "reference": "Patient/SubscriberExample"
  },
  "created": "2005-05-02T11:02:00+05:00",
  "insurer": {
    "reference": "Organization/InsurerExample"
  },
  "requestor": {
    "reference": "Organization/UMOExample"
  },
  "request": {
    "reference": "Claim/ReferralAuthorizationExample"
  },
  "outcome": "error",
  "error": [
    {
      "code": {
        "coding": [
          {
            "system": "https://codesystem.x12.org/005010/901",
            "code": "04"
          }
        ]
      }
    },
    {
      "extension": [
        {
          "extension": [
            {
              "url": "error",
              "valueString": "2010A-NM103"
            }
          ],
          "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement"
        },
        {
          "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath",
          "valueString": "Bundle.entry[1].Organization.name"
        },
        {
          "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "https://codesystem.x12.org/005010/889",
                "code": "C"
              }
            ]
          }
        }
      ],
      "code": {
        "coding": [
          {
            "system": "https://codesystem.x12.org/005010/901",
            "code": "T4"
          }
        ]
      }
    }
  ]
}