Message: Claim Institutional Response #1 - Healthcare Financial Services IG Edition 1 v0.3.0

Healthcare Financial Services IG Edition 1 - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Bundle: Message: Claim Institutional Response #1

Generated Narrative: Bundle c2c63768-a65b-5784-ab91-6c09012c3cbc

Profile: Nphies Bundle

Bundle c2c63768-a65b-5784-ab91-6c09012c3cbc of type message

Entry 1 - fullUrl = urn:uuid:a7e4caf2-0441-40e5-97d2-5ae1802733af

Resource MessageHeader:

Generated Narrative: MessageHeader a7e4caf2-0441-40e5-97d2-5ae1802734af

Profile: Nphies MessageHeader
event: KSA Message Events claim-response: Claim Response
Destinations
- Receiver
* Identifier: http://nphies.sa/license/provider-license/PR-FHIR
sender: Identifier: http://nphies.sa/license/payer-license/INS-FHIR
source
Responses
- Identifier Code
* a7e4caf2-0441-40e5-97d2-5ae1802733af OK
focus: Bundle: type = message; timestamp = 2023-12-04 13:39:58+0000

Entry 2 - fullUrl = http://sni.com.sa/ClaimResponse/48100

Resource ClaimResponse:

Generated Narrative: ClaimResponse 48100

Profile: Nphies Claim Response
Adjudication Outcome: Approved
identifier: http://sni.com.sa/identifiers/claimresponse/res_683514
status: Active
type: Institutional
subType: InPatient
use: Claim
patient: Sara Abbas Female, DoB: 1989-03-13 ( Permanent Resident Card Number: 2000000003)
created: 2023-12-06
insurer: Organization Saudi National Insurance
requestor: Organization Saudi General Hospital
request: Identifier: http://saudigeneralhospital.com.sa/identifiers/claim/req_3085
outcome: complete
item
Adjudication Outcome: Approved
Patient Invoice: http://saudigeneralhospital.com.sa/identifiers/patientInvoice/Invc-20220120/IP-1110987
itemSequence: 1
adjudication
category: Eligible Amount
Amounts
- Value Currency
* 5000 SAR
adjudication
category: CoPay
Amounts
- Value Currency
* 0 SAR
adjudication
category: Benefit Amount
Amounts
- Value Currency
* 5000 SAR
adjudication
category: Approved Quantity
adjudication
category: Tax
Amounts
- Value Currency
* 750 SAR
item
Adjudication Outcome: Approved
Patient Invoice: http://saudigeneralhospital.com.sa/identifiers/patientInvoice/Invc-20220120/IP-1110987
itemSequence: 2
adjudication
category: Eligible Amount
Amounts
- Value Currency
* 300 SAR
adjudication
category: CoPay
Amounts
- Value Currency
* 0 SAR
adjudication
category: Benefit Amount
Amounts
- Value Currency
* 300 SAR
adjudication
category: Approved Quantity
adjudication
category: Tax
Amounts
- Value Currency
* 45 SAR
total
category: Eligible Amount
Amounts
- Value Currency
* 5300 SAR
total
category: Benefit Amount
Amounts
- Value Currency
* 5300 SAR
total
category: CoPay
Amounts
- Value Currency
* 0 SAR
total
category: Tax
Amounts
- Value Currency
* 795 SAR
Insurances
- Sequence Focal Coverage
* 1 true Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000003; status = active; type = extended healthcare; relationship = Spouse; network = Golden C

Entry 3 - fullUrl = http://sni.com.sa/Coverage/1985

Resource Coverage:

Generated Narrative: Coverage 1985

Profile: Nphies Coverage
identifier: http://sni.com.sa/identifiers/memberid/0000000003
status: Active
type: extended healthcare
policyHolder: Organization Policy Holder Organization
subscriber: Ahmad Khaled Abbas(official) Male, DoB: 1984-12-25 ( Passport Number: G12345678)
beneficiary: Sara Abbas Female, DoB: 1989-03-13 ( Permanent Resident Card Number: 2000000003)
relationship: Spouse
Classes
- Type Value Name
* Plan ABC123 Insurance Plan A
network: Golden C

Entry 4 - fullUrl = http://sni.com.sa/Organization/13

Resource Organization:

Generated Narrative: Organization 13

Profile: Nphies Policy Holder Organization
identifier: http://nphies.sa/identifiers/organization/5009
active: true
name: Policy Holder Organization

Entry 5 - fullUrl = http://sni.com.sa/Organization/b1b3432921324f97af3be9fd0b1a14ae

Resource Organization:

Generated Narrative: Organization b1b3432921324f97af3be9fd0b1a14ae

Profile: Nphies Provider Organization
Provider Type: Hospital
identifier: http://nphies.sa/license/provider-license/PR-FHIR
active: true
type: Healthcare Provider
name: Saudi General Hospital
Contacts
- Address
* Salamah Street, Building 25, Suite 2, Riyadh Saudi Arabia(work)

Entry 6 - fullUrl = http://sni.com.sa/Patient/453

Resource Patient:

Generated Narrative: Patient 453

Profile: Nphies Patient
Sara Abbas Female, DoB: 1989-03-13 ( Permanent Resident Card Number: 2000000003)
Active: true Marital Status: Married
Patient Occupation Housewife

Entry 7 - fullUrl = http://sni.com.sa/Patient/123454186

Resource Patient:

Generated Narrative: Patient 123454186

Profile: Nphies Patient
Ahmad Khaled Abbas(official) Male, DoB: 1984-12-25 ( Passport Number: G12345678)
Active: true Deceased: false
Marital Status: Married
Contact Detail
+966512345691
Salamah Street, Building 25, Suite 2, Saudi Arabia(home)
Patient Occupation Business

Entry 8 - fullUrl = http://sni.com.sa/Organization/bff3aa1fbd3648619ac082357bf135db

Resource Organization:

Generated Narrative: Organization bff3aa1fbd3648619ac082357bf135db

Profile: Nphies Insurer Organization
identifier: National Insurance Organization Identifier/INS-FHIR (use: official, )
active: true
type: Insurance Company
name: Saudi National Insurance
Contacts
- Address
* Olaya Street, Building 70, Riyadh Saudi Arabia(work)