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Source1

{
  "resourceType": "ClaimResponse",
  "id": "ClaimResponse-predetermination-example-01",
  "meta": {
    "profile": [
      "https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "737481003",
        "display": "Inpatient care management (procedure)"
      }
    ]
  },
  "use": "predetermination",
  "patient": {
    "reference": "Patient/example-01"
  },
  "created": "2023-12-12T15:32:26.605+05:30",
  "insurer": {
    "reference": "Organization/example-02"
  },
  "requestor": {
    "reference": "Organization/example-03"
  },
  "request": {
    "reference": "Claim/Claim-predetermination-example-01"
  },
  "outcome": "complete",
  "preAuthRef": "123456",
  "payeeType": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/payeetype",
        "code": "provider"
      }
    ]
  },
  "item": [
    {
      "itemSequence": 1,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "submitted",
                "display": "Submitted Amount"
              }
            ]
          },
          "amount": {
            "value": 10000,
            "currency": "INR"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligpercent",
                "display": "Eligible %"
              }
            ]
          },
          "reason": {
            "coding": [
              {
                "system": "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
                "code": "covered",
                "display": "Product or Service requested is covered by the policy."
              }
            ]
          },
          "amount": {
            "value": 10000,
            "currency": "INR"
          }
        }
      ]
    },
    {
      "itemSequence": 2,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "submitted",
                "display": "Submitted Amount"
              }
            ]
          },
          "amount": {
            "value": 40000,
            "currency": "INR"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligpercent",
                "display": "Eligible %"
              }
            ]
          },
          "reason": {
            "coding": [
              {
                "system": "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
                "code": "covered",
                "display": "Product or Service requested is covered by the policy."
              }
            ]
          },
          "amount": {
            "value": 40000,
            "currency": "INR"
          }
        }
      ]
    },
    {
      "itemSequence": 3,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "submitted",
                "display": "Submitted Amount"
              }
            ]
          },
          "amount": {
            "value": 20000,
            "currency": "INR"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligpercent",
                "display": "Eligible %"
              }
            ]
          },
          "reason": {
            "coding": [
              {
                "system": "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
                "code": "covered",
                "display": "Product or Service requested is covered by the policy."
              }
            ]
          },
          "amount": {
            "value": 20000,
            "currency": "INR"
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted",
            "display": "Submitted Amount"
          }
        ]
      },
      "amount": {
        "value": 70000,
        "currency": "INR"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "eligpercent",
            "display": "Eligible %"
          }
        ]
      },
      "amount": {
        "value": 70000,
        "currency": "INR"
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/example-01"
      }
    }
  ]
}