This is the exact FHIR Claim resource that DTR assembled and
POSTed to PAS via Claim/$submit in the run behind the uncut write-up
— the same payload whose PENDING flipped to GRANTED fifteen
seconds later. Shown exactly as the payer accepted it: patient pat013, diagnosis
E11.21, the CQL-checked attestation, and the supporting note. Nothing prettified,
nothing trimmed.
{
"resourceType": "Claim",
"id": "a5fb2468-d91a-41a3-8ea1-0eafd99e97b6",
"identifier": [
{
"system": "urn:uuid:mitre-drls",
"value": "4u5_167Yi"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional",
"display": "Professional"
}
]
},
"use": "preauthorization",
"patient": {
"reference": "Patient/pat013"
},
"created": "2026-10-16T21:30:08.391Z",
"insurer": {
"reference": "Organization/org1234"
},
"provider": {
"reference": "Practitioner/pra1234"
},
"priority": {
"coding": [
{
"code": "normal"
}
]
},
"facility": {
"reference": "Location/loc1234"
},
"careTeam": [
{
"extension": [
{
"url": "http://terminology.hl7.org/ValueSet/v2-0912",
"valueCode": "OP"
}
],
"sequence": 1,
"provider": {
"reference": "Practitioner/pra1234"
}
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://hl7.org/us/davinci-pas/CodeSystem/PASSupportingInfoType",
"code": "patientEvent"
}
]
},
"timingPeriod": {
"start": "2020-01-01",
"end": "2021-01-01"
}
},
{
"sequence": 2,
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code": "info",
"display": "Information"
}
]
},
"valueReference": {
"reference": "QuestionnaireResponse/undefined"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true
}
],
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "E0607",
"display": "Home blood glucose monitor"
}
]
},
"quantity": {
"value": 1
}
}
]
}
Prefer it raw? Download the exact JSON file “davinci-claim-…json” — it
is also bundled next to the staged write-up as
assets/davinci-claim-….json.