{
  "resourceType" : "ClaimResponse",
  "id" : "self-assessment-example",
  "meta" : {
    "profile" : ["https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas"]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-ClaimResponse-twpas.html\">事前審查結果-ClaimResponse TWPAS</a></p></div><p><b>狀態</b>：Active</p><p><b>審查委員身分證號</b>：F123456789（http://www.moi.gov.tw）、A123456789（http://www.moi.gov.tw）</p><p><b>類型</b>：<span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>用途</b>：Preauthorization</p><p><b>病人</b>：<a href=\"Patient-pat-min.html\">Patient/pat-min</a></p><p><b>核定日期</b>：2024-07-30</p><p><b>保險商</b>：<a href=\"Organization-org-nhi.html\">Organization 衛生福利部中央健康保險署</a></p><p><b>處置狀態</b>：Processing Complete</p><blockquote><p><b>item</b></p><p><b>itemSequence</b>：1</p><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>類型</b></td><td><b>核定註記</b></td><td><b>審查結果數量</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></td><td><span title=\"Codes:{https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-approve-comment 1}\">同意備查</span></td><td>5</td></tr></table></blockquote></div>"
  },
  "extension" : [{
    "url" : "https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor",
    "valueIdentifier" : {
      "system" : "http://www.moi.gov.tw",
      "value" : "F123456789"
    }
  },
  {
    "url" : "https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor",
    "valueIdentifier" : {
      "system" : "http://www.moi.gov.tw",
      "value" : "A123456789"
    }
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "institutional"
    }]
  },
  "use" : "preauthorization",
  "patient" : {
    "reference" : "Patient/pat-min"
  },
  "created" : "2024-07-30",
  "insurer" : {
    "reference" : "Organization/org-nhi"
  },
  "outcome" : "complete",
  "item" : [{
    "itemSequence" : 1,
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "code" : "submitted"
        }]
      },
      "reason" : {
        "coding" : [{
          "system" : "https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-approve-comment",
          "code" : "1"
        }]
      },
      "value" : 5
    }]
  }]
}