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 Professional Request #1 - XML Representation
<Claim xmlns="http://hl7.org/fhir">
<id value="173386"/>
<meta>
<profile
value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/professional-claim"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim 173386</b></p><a name="173386"> </a><a name="hc173386"> </a><a name="173386-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-professional-claim.html">Nphies Claim Professional</a></p></div><p><b>Encounter</b>: <a href="Encounter-10131.html">Encounter: extension = Urgent,2023-12-05 11:38:32+0300,Initial client service event,Ground EMS Ambulance,2023-12-05 11:38:32+0300,Died in ED,Mycoplasma infection, unspecified; identifier = http://saudiprofessional.com.sa/identifiers/encounter#AB0011; status = finished; class = emergency (ActCode#EMER); serviceType = Sub-Acute Care; priority = emergency; period = 2023-12-05 08:38:00+0300 --> 2023-12-06 11:38:00+0300</a></p><p><b>Authorization Offline Date</b>: 2023-12-05 11:05:48+0300</p><p><b>Episode</b>: <code>http://saudiprofessionalclinic.com.sa/identifiers/episode</code>/provider_EpisodeID_2314596</p><p><b>identifier</b>: <code>http://saudiprofessionalclinic.com.sa/identifiers/claim</code>/req_17307786</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</span></p><p><b>subType</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-subtype emr}">Emergency</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href="Patient-3662364643.html">Maria Khaled Rizwan(official) Female, DoB: 1990-12-25 ( Permanent Resident Card Number: 2000000010)</a></p><p><b>created</b>: 2023-12-05 12:21:15+0300</p><p><b>insurer</b>: <a href="Organization-bff3aa1fbd3648619ac082357bf135db.html">Organization Saudi National Insurance</a></p><p><b>provider</b>: <a href="Organization-5025.html">Organization Saudi Professional 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-2.html">Practitioner Dr. Amar Moustafa(official)</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 08.02}">Cardiology</span></td></tr></table><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category vital-sign-systolic}">Systolic</span></p><p><b>timing</b>: 2023-12-05 12:21:15+0300 --> 2023-12-05 12:21:15+0300</p><p><b>value</b>: 120 mm[Hg]<span style="background: LightGoldenRodYellow"> (Details: UCUM codemm[Hg] = 'mm[Hg]')</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category vital-sign-diastolic}">Diastolic</span></p><p><b>timing</b>: 2023-12-05 12:21:15+0300 --> 2023-12-05 12:21:15+0300</p><p><b>value</b>: 80 mm[Hg]<span style="background: LightGoldenRodYellow"> (Details: UCUM codemm[Hg] = 'mm[Hg]')</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category vital-sign-height}">Height</span></p><p><b>timing</b>: 2023-12-05 12:21:15+0300 --> 2023-12-05 12:21:15+0300</p><p><b>value</b>: 133 cm<span style="background: LightGoldenRodYellow"> (Details: UCUM codecm = 'cm')</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category vital-sign-weight}">Weight</span></p><p><b>timing</b>: 2023-12-05 12:21:15+0300 --> 2023-12-05 12:21:15+0300</p><p><b>value</b>: 50 kg<span style="background: LightGoldenRodYellow"> (Details: UCUM codekg = 'kg')</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category pulse}">Pulse</span></p><p><b>timing</b>: 2023-12-05 12:21:15+0300 --> 2023-12-05 12:21:15+0300</p><p><b>value</b>: 100 /min<span style="background: LightGoldenRodYellow"> (Details: UCUM code/min = '/min')</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category temperature}">Temperature</span></p><p><b>timing</b>: 2023-12-05 12:21:15+0300 --> 2023-12-05 12:21:15+0300</p><p><b>value</b>: 37 Cel<span style="background: LightGoldenRodYellow"> (Details: UCUM codeCel = 'Cel')</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category chief-complaint}">chief complaint</span></p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 426749004}">Chronic atrial fibrillation (disorder)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category oxygen-saturation}">Oxygen Saturation</span></p><p><b>timing</b>: 2023-12-05 12:21:15+0300 --> 2023-12-05 12:21:15+0300</p><p><b>value</b>: 100 %<span style="background: LightGoldenRodYellow"> (Details: UCUM code% = '%')</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category respiratory-rate}">Respiratory Rate</span></p><p><b>timing</b>: 2023-12-05 12:21:15+0300 --> 2023-12-05 12:21:15+0300</p><p><b>value</b>: 18 /min<span style="background: LightGoldenRodYellow"> (Details: UCUM code/min = '/min')</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 10</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category patient-history}">patient history</span></p><p><b>value</b>: No systemic disease</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 11</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category investigation-result}">Investigation Result</span></p><p><b>code</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/investigation-result INP}">Investigation(s) not performed</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 12</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category treatment-plan}">Treatment Plan</span></p><p><b>value</b>: Analgesic Drugs</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 13</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category physical-examination}">Physical Examination</span></p><p><b>value</b>: Stable</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 14</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category history-of-present-illness}">history Of Present Illness</span></p><p><b>value</b>: No history</p></blockquote><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 I48.2}">Chronic atrial fibrillation</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><td><b>PreAuthRef</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-1445.html">Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000002; status = active; type = extended healthcare; relationship = Self; network = Golden C</a></td><td>DEF987</td></tr></table><blockquote><p><b>item</b></p><p><b>Patient Share</b>: <span title="Saudi Riyal">SAR20.00</span> (SAR)</p><p><b>Package Code</b>: false</p><p><b>Tax</b>: <span title="Saudi Riyal">SAR75.00</span> (SAR)</p><p><b>Patient Invoice</b>: <code>http://saudiprofessionalclinic.com.sa/identifiers/patientInvoice</code>/Invc-20220120/OP-883923</p><p><b>Maternity</b>: false</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/services 83600-00-10}">Office Assessment for diagnosis treatment and counselling of a new or established patient by Specialist</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>500</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>575</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>575</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/10131"/>
</valueReference>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-authorization-offline-date">
<valueDateTime value="2023-12-05T11:05:48+03:00"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-episode">
<valueIdentifier>
<system
value="http://saudiprofessionalclinic.com.sa/identifiers/episode"/>
<value value="provider_EpisodeID_2314596"/>
</valueIdentifier>
</extension>
<identifier>
<system value="http://saudiprofessionalclinic.com.sa/identifiers/claim"/>
<value value="req_17307786"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
</coding>
</type>
<subType>
<coding>
<system value="http://nphies.sa/terminology/CodeSystem/claim-subtype"/>
<code value="emr"/>
</coding>
</subType>
<use value="claim"/>
<patient>🔗
<reference value="Patient/3662364643"/>
</patient>
<created value="2023-12-05T12:21:15.23+03:00"/>
<insurer>🔗
<reference value="Organization/bff3aa1fbd3648619ac082357bf135db"/>
</insurer>
<provider>🔗
<reference value="Organization/5025"/>
</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/2"/>
</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="08.02"/>
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="vital-sign-systolic"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:21:15.23+03:00"/>
<end value="2023-12-05T12:21:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="120"/>
<system value="http://unitsofmeasure.org"/>
<code value="mm[Hg]"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="vital-sign-diastolic"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:21:15.23+03:00"/>
<end value="2023-12-05T12:21:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="80"/>
<system value="http://unitsofmeasure.org"/>
<code value="mm[Hg]"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="vital-sign-height"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:21:15.23+03:00"/>
<end value="2023-12-05T12:21:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="133"/>
<system value="http://unitsofmeasure.org"/>
<code value="cm"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="vital-sign-weight"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:21:15.23+03:00"/>
<end value="2023-12-05T12:21:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="50"/>
<system value="http://unitsofmeasure.org"/>
<code value="kg"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="5"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="pulse"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:21:15.23+03:00"/>
<end value="2023-12-05T12:21:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="100"/>
<system value="http://unitsofmeasure.org"/>
<code value="/min"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="6"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="temperature"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:21:15.23+03:00"/>
<end value="2023-12-05T12:21:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="37"/>
<system value="http://unitsofmeasure.org"/>
<code value="Cel"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="7"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="chief-complaint"/>
</coding>
</category>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="426749004"/>
<display value="Chronic atrial fibrillation (disorder)"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="8"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="oxygen-saturation"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:21:15.23+03:00"/>
<end value="2023-12-05T12:21:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="100"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="9"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="respiratory-rate"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:21:15.23+03:00"/>
<end value="2023-12-05T12:21:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="18"/>
<system value="http://unitsofmeasure.org"/>
<code value="/min"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="10"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="patient-history"/>
</coding>
</category>
<valueString value="No systemic disease"/>
</supportingInfo>
<supportingInfo>
<sequence value="11"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="investigation-result"/>
</coding>
</category>
<code>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/investigation-result"/>
<code value="INP"/>
<display value="Investigation(s) not performed"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="12"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="treatment-plan"/>
</coding>
</category>
<valueString value="Analgesic Drugs"/>
</supportingInfo>
<supportingInfo>
<sequence value="13"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="physical-examination"/>
</coding>
</category>
<valueString value="Stable"/>
</supportingInfo>
<supportingInfo>
<sequence value="14"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="history-of-present-illness"/>
</coding>
</category>
<valueString value="No history"/>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-am"/>
<code value="I48.2"/>
<display value="Chronic atrial fibrillation"/>
</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/1445"/>
</coverage>
<preAuthRef value="DEF987"/>
</insurance>
<item>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-share">
<valueMoney>
<value value="20"/>
<currency value="SAR"/>
</valueMoney>
</extension>
<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="75"/>
<currency value="SAR"/>
</valueMoney>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice">
<valueIdentifier>
<system
value="http://saudiprofessionalclinic.com.sa/identifiers/patientInvoice"/>
<value value="Invc-20220120/OP-883923"/>
</valueIdentifier>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-maternity">
<valueBoolean value="false"/>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<productOrService>
<coding>
<system value="http://nphies.sa/terminology/CodeSystem/services"/>
<code value="83600-00-10"/>
<display
value="Office Assessment for diagnosis treatment and counselling of a new or established patient by Specialist"/>
</coding>
</productOrService>
<servicedDate value="2023-12-05"/>
<quantity>
<value value="1"/>
</quantity>
<unitPrice>
<value value="500"/>
<currency value="SAR"/>
</unitPrice>
<net>
<value value="575"/>
<currency value="SAR"/>
</net>
</item>
<total>
<value value="575"/>
<currency value="SAR"/>
</total>
</Claim>