Healthcare Financial Services IG Edition 1
0.3.0 - ci-build
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
: Claim Oral Request #2 - XML Representation
<Claim xmlns="http://hl7.org/fhir">
<id value="173094"/>
<meta>
<profile
value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/oral-claim"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim 173094</b></p><a name="173094"> </a><a name="hc173094"> </a><a name="173094-en-US"> </a><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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-oral-claim.html">Nphies Claim Oral</a></p></div><p><b>Encounter</b>: <a href="Encounter-10132.html">Encounter: extension = Initial client service event; identifier = http://saudidentalclinic.com.sa/identifiers/encounter#AB0032; status = finished; class = ambulatory (ActCode#AMB); serviceType = Dental Care; priority = elective; period = 2023-12-04 --> (ongoing)</a></p><p><b>Episode</b>: <code>http://saudidentalclinic.com.sa/identifiers/episode</code>/SDC_EpisodeID_48903211</p><p><b>identifier</b>: <code>http://saudidentalclinic.com.sa/identifiers/claim</code>/req_29309905401</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type oral}">Oral</span></p><p><b>subType</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-subtype op}">OutPatient</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href="Patient-453.html">Sara Abbas Female, DoB: 1989-03-13 ( Permanent Resident Card Number: 2000000003)</a></p><p><b>created</b>: 2023-12-04 08:38:00+0300</p><p><b>insurer</b>: <a href="Organization-bff3aa1fbd3648619ac082357bf135db.html">Organization Saudi National Insurance</a></p><p><b>provider</b>: <a href="Organization-215.html">Organization Saudi Dental Clinic</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}">Provider</span></td></tr></table><h3>CareTeams</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td><td><b>Qualification</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><a href="Practitioner-4.html">Practitioner Dr. Ashraf Naeem</a></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/claimcareteamrole primary}">Primary provider</span></td><td><span title="Codes:{http://nphies.sa/terminology/CodeSystem/practice-codes 22.00}">Dental</span></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{http://hl7.org/fhir/sid/icd-10-am K02.0}">Caries limited to enamel</span></td><td><span title="Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-type principal}">Principal Diagnosis</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-1985.html">Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000003; status = active; type = extended healthcare; relationship = Spouse; network = Golden C</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Package Code</b>: false</p><p><b>Tax</b>: <span title="Saudi Riyal">SAR30.00</span> (SAR)</p><p><b>Patient Share</b>: <span title="Saudi Riyal">SAR40.00</span> (SAR)</p><p><b>Patient Invoice</b>: <code>http://saudigeneralhospital.com.sa/identifiers/patientInvoice</code>/Invc-20220120/IP-1110987</p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>diagnosisSequence</b>: 1</p><p><b>productOrService</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/oral-health-op 97521-01-00}">Adhesive restor tooth 1 surf direct</span></p><p><b>serviced</b>: 2023-12-05</p><p><b>quantity</b>: 1</p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>Saudi riyal</td></tr></table><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>230</td><td>Saudi riyal</td></tr></table></blockquote><h3>Totals</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>230</td><td>Saudi riyal</td></tr></table></div>
</text>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-encounter">
<valueReference>🔗
<reference value="Encounter/10132"/>
</valueReference>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-episode">
<valueIdentifier>
<system value="http://saudidentalclinic.com.sa/identifiers/episode"/>
<value value="SDC_EpisodeID_48903211"/>
</valueIdentifier>
</extension>
<identifier>
<system value="http://saudidentalclinic.com.sa/identifiers/claim"/>
<value value="req_29309905401"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="oral"/>
</coding>
</type>
<subType>
<coding>
<system value="http://nphies.sa/terminology/CodeSystem/claim-subtype"/>
<code value="op"/>
</coding>
</subType>
<use value="claim"/>
<patient>🔗
<reference value="Patient/453"/>
</patient>
<created value="2023-12-04T08:38:00+03:00"/>
<insurer>🔗
<reference value="Organization/bff3aa1fbd3648619ac082357bf135db"/>
</insurer>
<provider>🔗
<reference value="Organization/215"/>
</provider>
<priority>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<payee>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
</coding>
</type>
</payee>
<careTeam>
<sequence value="1"/>
<provider>🔗
<reference value="Practitioner/4"/>
</provider>
<role>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claimcareteamrole"/>
<code value="primary"/>
</coding>
</role>
<qualification>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/practice-codes"/>
<code value="22.00"/>
</coding>
</qualification>
</careTeam>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-am"/>
<code value="K02.0"/>
<display value="Caries limited to enamel"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/diagnosis-type"/>
<code value="principal"/>
</coding>
</type>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/1985"/>
</coverage>
</insurance>
<item>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-package">
<valueBoolean value="false"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-tax">
<valueMoney>
<value value="30"/>
<currency value="SAR"/>
</valueMoney>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-share">
<valueMoney>
<value value="40"/>
<currency value="SAR"/>
</valueMoney>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice">
<valueIdentifier>
<system
value="http://saudigeneralhospital.com.sa/identifiers/patientInvoice"/>
<value value="Invc-20220120/IP-1110987"/>
</valueIdentifier>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<productOrService>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/oral-health-op"/>
<code value="97521-01-00"/>
<display value="Adhesive restor tooth 1 surf direct"/>
</coding>
</productOrService>
<servicedDate value="2023-12-05"/>
<quantity>
<value value="1"/>
</quantity>
<unitPrice>
<value value="200"/>
<currency value="SAR"/>
</unitPrice>
<net>
<value value="230"/>
<currency value="SAR"/>
</net>
</item>
<total>
<value value="230"/>
<currency value="SAR"/>
</total>
</Claim>