{"resourceType":"Bundle","id":"pas-request-AUT-2026-00187","meta":{"profile":["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"]},"type":"collection","timestamp":"2026-07-16T01:26:39.362Z","entry":[{"fullUrl":"urn:uuid:b43a8997-40c6-442c-86b4-22563860eff8","resource":{"resourceType":"Claim","id":"b43a8997-40c6-442c-86b4-22563860eff8","meta":{"profile":["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"]},"identifier":[{"system":"https://authora.health/cases","value":"AUT-2026-00187"}],"status":"active","type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/claim-type","code":"institutional"}]},"use":"preauthorization","patient":{"reference":"urn:uuid:57cf3db0-cea2-4f78-bf70-2ed81d1b8cb3"},"created":"2026-05-08T14:06:00.000Z","insurer":{"reference":"urn:uuid:67c1265a-271f-4788-907e-f730ce0f99d6"},"provider":{"reference":"urn:uuid:969162b3-9845-4639-be66-060a63e9b109"},"priority":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/processpriority","code":"normal"}]},"careTeam":[{"sequence":1,"provider":{"reference":"urn:uuid:151d0b48-5455-4064-8c22-28195f08bfbc"},"role":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/claimcareteamrole","code":"primary"}]}}],"diagnosis":[{"sequence":1,"diagnosisCodeableConcept":{"coding":[{"system":"http://hl7.org/fhir/sid/icd-10-cm","code":"M54.50","display":"Low back pain, unspecified"}]}},{"sequence":2,"diagnosisCodeableConcept":{"coding":[{"system":"http://hl7.org/fhir/sid/icd-10-cm","code":"M51.36","display":"Other intervertebral disc degeneration, lumbar region"}]}},{"sequence":3,"diagnosisCodeableConcept":{"coding":[{"system":"http://hl7.org/fhir/sid/icd-10-cm","code":"M54.16","display":"Radiculopathy, lumbar region"}]}}],"insurance":[{"sequence":1,"focal":true,"coverage":{"reference":"urn:uuid:b87d83ce-50b6-4232-aea0-5931909a6e00"}}],"item":[{"sequence":1,"careTeamSequence":[1],"diagnosisSequence":[1,2,3],"productOrService":{"coding":[{"system":"http://www.ama-assn.org/go/cpt","code":"72148","display":"MRI lumbar spine without contrast"}]},"servicedDate":"2026-05-10","extension":[{"url":"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail","valueCodeableConcept":{"coding":[{"system":"https://codesystem.x12.org/005010/1525","code":"SC","display":"Specialty Care Review"}]}}]}]}},{"fullUrl":"urn:uuid:57cf3db0-cea2-4f78-bf70-2ed81d1b8cb3","resource":{"resourceType":"Patient","id":"57cf3db0-cea2-4f78-bf70-2ed81d1b8cb3","identifier":[{"system":"http://hl7.org/fhir/sid/us-mbi","value":"ANTH-W123456789"},{"system":"https://authora.health/mrn","value":"MRN-008814"}],"name":[{"family":"Park","given":["Min-Jee"]}],"gender":"female","birthDate":"1962-04-12","address":[{"state":"CA","country":"US"}]}},{"fullUrl":"urn:uuid:b87d83ce-50b6-4232-aea0-5931909a6e00","resource":{"resourceType":"Coverage","id":"b87d83ce-50b6-4232-aea0-5931909a6e00","status":"active","subscriberId":"ANTH-W123456789","beneficiary":{"reference":"urn:uuid:57cf3db0-cea2-4f78-bf70-2ed81d1b8cb3"},"payor":[{"reference":"urn:uuid:67c1265a-271f-4788-907e-f730ce0f99d6"}],"class":[{"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/coverage-class","code":"plan"}]},"value":"Anthem PPO Gold"}]}},{"fullUrl":"urn:uuid:67c1265a-271f-4788-907e-f730ce0f99d6","resource":{"resourceType":"Organization","id":"67c1265a-271f-4788-907e-f730ce0f99d6","identifier":[{"system":"https://hl7.org/fhir/sid/us-payer","value":"anthem"}],"name":"Anthem (Elevance Health)","type":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/organization-type","code":"ins"}]}]}},{"fullUrl":"urn:uuid:969162b3-9845-4639-be66-060a63e9b109","resource":{"resourceType":"Organization","id":"969162b3-9845-4639-be66-060a63e9b109","name":"Oakwood Primary Care","type":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/organization-type","code":"prov"}]}]}},{"fullUrl":"urn:uuid:151d0b48-5455-4064-8c22-28195f08bfbc","resource":{"resourceType":"Practitioner","id":"151d0b48-5455-4064-8c22-28195f08bfbc","identifier":[{"system":"http://hl7.org/fhir/sid/us-npi","value":"1689345712"}],"name":[{"family":"Okonkwo","given":["Chinedu"],"suffix":["MD"]}]}}]}