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Source1

{
  "resourceType": "ClaimResponse",
  "id": "PractitionerRequestorPendingResponseExample",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "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": "PractitionerRole/ReferralPractitionerRoleExample"
  },
  "request": {
    "reference": "Claim/ReferralAuthorizationExample"
  },
  "outcome": "complete",
  "item": [
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
          "valueString": "PEND0001"
        }
      ],
      "itemSequence": 1,
      "adjudication": [
        {
          "extension": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
                  "valueCodeableConcept": {
                    "coding": [
                      {
                        "system": "https://codesystem.x12.org/005010/306",
                        "code": "A4",
                        "display": "Pending"
                      }
                    ]
                  }
                }
              ],
              "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
            }
          ],
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "submitted"
              }
            ]
          }
        }
      ]
    }
  ]
}