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
: Authorization Oral Request #1 - JSON Representation
{
"resourceType" : "Claim",
"id" : "293093",
"meta" : {
"profile" : [
🔗 "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/oral-priorauth"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim 293093</b></p><a name=\"293093\"> </a><a name=\"hc293093\"> </a><a name=\"293093-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-priorauth.html\">Nphies Authorization Oral</a></p></div><p><b>Encounter</b>: <a href=\"Encounter-10123.html\">Encounter: extension = Initial client service event; identifier = http://saudidentalclinic.com.sa/identifiers/encounter#AB0001; status = in-progress; class = ambulatory (ActCode#AMB); serviceType = Acute Care; priority = elective; period = 2023-12-04 --> (ongoing)</a></p><p><b>identifier</b>: <code>http://saudidentalclinic.com.sa/identifiers/authorization</code>/req_293093</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>: Preauthorization</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}\">K02.0</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>Patient Share</b>: <span title=\"Saudi Riyal\">SAR40.00</span> (SAR)</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 97011-00-00}\">Comprehensive oral examination</span></p><p><b>serviced</b>: 2023-12-04</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>200</td><td>Saudi riyal</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>Package Code</b>: false</p><p><b>Patient Share</b>: <span title=\"Saudi Riyal\">SAR60.00</span> (SAR)</p><p><b>sequence</b>: 2</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 97043-00-00}\">Dental antibiotic sensitivity test</span></p><p><b>serviced</b>: 2023-12-04</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>300</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>300</td><td>Saudi riyal</td></tr></table><p><b>bodySite</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/fdi-oral-region 13}\">UPPER RIGHT; PERMANENT TEETH # 3</span></p></blockquote><blockquote><p><b>item</b></p><p><b>Package Code</b>: false</p><p><b>Patient Share</b>: <span title=\"Saudi Riyal\">SAR100.00</span> (SAR)</p><p><b>sequence</b>: 3</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 97613-07-00}\">Lithium disilicate ceramic crown (e max), indirect; per crown</span></p><p><b>serviced</b>: 2023-12-04</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>1300</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>1300</td><td>Saudi riyal</td></tr></table><p><b>bodySite</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/fdi-oral-region 37}\">LOWER LEFT; PERMANENT TEETH # 7</span></p></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>1800</td><td>Saudi riyal</td></tr></table></div>"
},
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-encounter",
"valueReference" : {
🔗 "reference" : "Encounter/10123"
}
}
],
"identifier" : [
{
"system" : "http://saudidentalclinic.com.sa/identifiers/authorization",
"value" : "req_293093"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "oral"
}
]
},
"subType" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code" : "op"
}
]
},
"use" : "preauthorization",
"patient" : {
🔗 "reference" : "Patient/453"
},
"created" : "2023-12-04T08:38:00+03:00",
"insurer" : {
🔗 "reference" : "Organization/bff3aa1fbd3648619ac082357bf135db"
},
"provider" : {
🔗 "reference" : "Organization/215"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"payee" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}
]
}
},
"careTeam" : [
{
"sequence" : 1,
"provider" : {
🔗 "reference" : "Practitioner/4"
},
"role" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
"code" : "primary"
}
]
},
"qualification" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/practice-codes",
"code" : "22.00"
}
]
}
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-am",
"code" : "K02.0"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/diagnosis-type",
"code" : "principal"
}
]
}
]
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/1985"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-package",
"valueBoolean" : false
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-share",
"valueMoney" : {
"value" : 40,
"currency" : "SAR"
}
}
],
"sequence" : 1,
"careTeamSequence" : [
1
],
"diagnosisSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/oral-health-op",
"code" : "97011-00-00",
"display" : "Comprehensive oral examination"
}
]
},
"servicedDate" : "2023-12-04",
"quantity" : {
"value" : 1
},
"unitPrice" : {
"value" : 200,
"currency" : "SAR"
},
"net" : {
"value" : 200,
"currency" : "SAR"
}
},
{
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-package",
"valueBoolean" : false
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-share",
"valueMoney" : {
"value" : 60,
"currency" : "SAR"
}
}
],
"sequence" : 2,
"careTeamSequence" : [
1
],
"diagnosisSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/oral-health-op",
"code" : "97043-00-00",
"display" : "Dental antibiotic sensitivity test"
}
]
},
"servicedDate" : "2023-12-04",
"quantity" : {
"value" : 1
},
"unitPrice" : {
"value" : 300,
"currency" : "SAR"
},
"net" : {
"value" : 300,
"currency" : "SAR"
},
"bodySite" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/fdi-oral-region",
"code" : "13",
"display" : "UPPER RIGHT; PERMANENT TEETH # 3"
}
]
}
},
{
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-package",
"valueBoolean" : false
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-share",
"valueMoney" : {
"value" : 100,
"currency" : "SAR"
}
}
],
"sequence" : 3,
"careTeamSequence" : [
1
],
"diagnosisSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/oral-health-op",
"code" : "97613-07-00",
"display" : "Lithium disilicate ceramic crown (e max), indirect; per crown"
}
]
},
"servicedDate" : "2023-12-04",
"quantity" : {
"value" : 1
},
"unitPrice" : {
"value" : 1300,
"currency" : "SAR"
},
"net" : {
"value" : 1300,
"currency" : "SAR"
},
"bodySite" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/fdi-oral-region",
"code" : "37",
"display" : "LOWER LEFT; PERMANENT TEETH # 7"
}
]
}
}
],
"total" : {
"value" : 1800,
"currency" : "SAR"
}
}