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

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: Authorization Oral Request #1 - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <id value="293093"/>
  <meta>
    <profile
             value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/oral-priorauth"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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 --&gt; (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>
  </text>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-encounter">
    <valueReference>🔗 
      <reference value="Encounter/10123"/>
    </valueReference>
  </extension>
  <identifier>
    <system
            value="http://saudidentalclinic.com.sa/identifiers/authorization"/>
    <value value="req_293093"/>
  </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="preauthorization"/>
  <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"/>
      </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-patient-share">
      <valueMoney>
        <value value="40"/>
        <currency value="SAR"/>
      </valueMoney>
    </extension>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <diagnosisSequence value="1"/>
    <productOrService>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/oral-health-op"/>
        <code value="97011-00-00"/>
        <display value="Comprehensive oral examination"/>
      </coding>
    </productOrService>
    <servicedDate value="2023-12-04"/>
    <quantity>
      <value value="1"/>
    </quantity>
    <unitPrice>
      <value value="200"/>
      <currency value="SAR"/>
    </unitPrice>
    <net>
      <value value="200"/>
      <currency value="SAR"/>
    </net>
  </item>
  <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-patient-share">
      <valueMoney>
        <value value="60"/>
        <currency value="SAR"/>
      </valueMoney>
    </extension>
    <sequence value="2"/>
    <careTeamSequence value="1"/>
    <diagnosisSequence value="1"/>
    <productOrService>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/oral-health-op"/>
        <code value="97043-00-00"/>
        <display value="Dental antibiotic sensitivity test"/>
      </coding>
    </productOrService>
    <servicedDate value="2023-12-04"/>
    <quantity>
      <value value="1"/>
    </quantity>
    <unitPrice>
      <value value="300"/>
      <currency value="SAR"/>
    </unitPrice>
    <net>
      <value value="300"/>
      <currency value="SAR"/>
    </net>
    <bodySite>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/fdi-oral-region"/>
        <code value="13"/>
        <display value="UPPER RIGHT; PERMANENT TEETH # 3"/>
      </coding>
    </bodySite>
  </item>
  <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-patient-share">
      <valueMoney>
        <value value="100"/>
        <currency value="SAR"/>
      </valueMoney>
    </extension>
    <sequence value="3"/>
    <careTeamSequence value="1"/>
    <diagnosisSequence value="1"/>
    <productOrService>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/oral-health-op"/>
        <code value="97613-07-00"/>
        <display
                 value="Lithium disilicate ceramic crown (e max), indirect; per crown"/>
      </coding>
    </productOrService>
    <servicedDate value="2023-12-04"/>
    <quantity>
      <value value="1"/>
    </quantity>
    <unitPrice>
      <value value="1300"/>
      <currency value="SAR"/>
    </unitPrice>
    <net>
      <value value="1300"/>
      <currency value="SAR"/>
    </net>
    <bodySite>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/fdi-oral-region"/>
        <code value="37"/>
        <display value="LOWER LEFT; PERMANENT TEETH # 7"/>
      </coding>
    </bodySite>
  </item>
  <total>
    <value value="1800"/>
    <currency value="SAR"/>
  </total>
</Claim>