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 Institutional Request #1 - JSON Representation
{
"resourceType" : "Claim",
"id" : "483069",
"meta" : {
"profile" : [
🔗 "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/institutional-priorauth"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim 483069</b></p><a name=\"483069\"> </a><a name=\"hc483069\"> </a><a name=\"483069-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-institutional-priorauth.html\">Nphies Authorization Institutional</a></p></div><p><b>Encounter</b>: <a href=\"Encounter-10124.html\">Encounter: identifier = http://saudigeneralhospital.com.sa/identifiers/encounter#AB0001; status = planned; class = short stay (ActCode#SS); serviceType = Sub-Acute Care; period = 2023-12-04 10:25:00+0300 --> 2023-12-04 12:30:00+0300</a></p><p><b>Eligibility Offline Reference</b>: EligResp-31212432</p><p><b>Eligibility Offline Date</b>: 2023-12-04</p><p><b>identifier</b>: <code>http://saudigeneralhospital.com.sa/identifiers/authorization</code>/req_1124856069</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>subType</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/claim-subtype ip}\">InPatient</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href=\"Patient-173826788.html\">Muhammad Khaled Abbas(official) Male, DoB: 2010-08-21 ( Permanent Resident Card Number: 2000000002)</a></p><p><b>created</b>: 2023-12-04 06:38:00+0300</p><p><b>insurer</b>: <a href=\"Organization-bff3aa1fbd3648619ac082357bf135db.html\">Organization Saudi National Insurance</a></p><p><b>provider</b>: <a href=\"Organization-b1b3432921324f97af3be9fd0b1a14ae.html\">Organization Saudi General Hospital</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-1.html\">Practitioner Dr. Ameera Hassan(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 08.26}\">General Medicine</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>: 2023-12-04 10:00:00+0300 --> 2023-12-04 11:00:00+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>: 2023-12-04 10:00:00+0300 --> 2023-12-04 11:00:00+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>: 2023-12-04 10:00:00+0300 --> 2023-12-04 11:00:00+0300</p><p><b>value</b>: 160 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>: 2023-12-04 10:00:00+0300 --> 2023-12-04 11:00:00+0300</p><p><b>value</b>: 129 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>: 2023-12-04 10:00:00+0300 --> 2023-12-04 11:00:00+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>: 2023-12-04 10:00:00+0300 --> 2023-12-04 11:00:00+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 28845006}\">Acute appendicitis with generalized peritonitis</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>: 2023-12-04 10:00:00+0300 --> 2023-12-04 11:00:00+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>: 2023-12-04 10:00:00+0300 --> 2023-12-04 11:00:00+0300</p><p><b>value</b>: 70 /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 admission-weight}\">Admission Weight</span></p><p><b>value</b>: 129 kg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codekg = 'kg')</span></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 estimated-Length-of-Stay}\">Estimated Length Of Stay</span></p><p><b>value</b>: 1 d<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM coded = 'd')</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 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>: 13</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>: 14</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>: Appendectomy</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 15</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>: 16</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><td><b>OnAdmission</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-am K35.2}\">Acute appendicitis with generalized peritonitis</span></td><td><span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-type principal}\">Principal Diagnosis</span></td><td><span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-on-admission n}\">No</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-1334.html\">Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000002; status = active; type = extended healthcare; relationship = Child; 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\">SAR0.00</span> (SAR)</p><p><b>Payer Share</b>: <span title=\"Saudi Riyal\">SAR400.00</span> (SAR)</p><p><b>Maternity</b>: false</p><p><b>Tax</b>: <span title=\"Saudi Riyal\">SAR100.00</span> (SAR)</p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>diagnosisSequence</b>: 1</p><p><b>informationSequence</b>: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16</p><p><b>productOrService</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/procedures 30571-00-00}\">Appendicectomy</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>400</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>400</td><td>Saudi riyal</td></tr></table></div>"
},
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-encounter",
"valueReference" : {
🔗 "reference" : "Encounter/10124"
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-eligibility-offline-reference",
"valueString" : "EligResp-31212432"
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-eligibility-offline-date",
"valueDateTime" : "2023-12-04"
}
],
"identifier" : [
{
"system" : "http://saudigeneralhospital.com.sa/identifiers/authorization",
"value" : "req_1124856069"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional"
}
]
},
"subType" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code" : "ip"
}
]
},
"use" : "preauthorization",
"patient" : {
🔗 "reference" : "Patient/173826788"
},
"created" : "2023-12-04T06:38:00+03:00",
"insurer" : {
🔗 "reference" : "Organization/bff3aa1fbd3648619ac082357bf135db"
},
"provider" : {
🔗 "reference" : "Organization/b1b3432921324f97af3be9fd0b1a14ae"
},
"priority" : {
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},
"payee" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}
]
}
},
"careTeam" : [
{
"sequence" : 1,
"provider" : {
🔗 "reference" : "Practitioner/1"
},
"role" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
"code" : "primary"
}
]
},
"qualification" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/practice-codes",
"code" : "08.26"
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]
}
}
],
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
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"code" : "vital-sign-systolic"
}
]
},
"timingPeriod" : {
"start" : "2023-12-04T10:00:00+03:00",
"end" : "2023-12-04T11:00:00+03:00"
},
"valueQuantity" : {
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"system" : "http://unitsofmeasure.org",
"code" : "mm[Hg]"
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},
{
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"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "vital-sign-diastolic"
}
]
},
"timingPeriod" : {
"start" : "2023-12-04T10:00:00+03:00",
"end" : "2023-12-04T11:00:00+03:00"
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"valueQuantity" : {
"value" : 80,
"system" : "http://unitsofmeasure.org",
"code" : "mm[Hg]"
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},
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
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"start" : "2023-12-04T10:00:00+03:00",
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"system" : "http://unitsofmeasure.org",
"code" : "cm"
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},
{
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"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
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}
]
},
"timingPeriod" : {
"start" : "2023-12-04T10:00:00+03:00",
"end" : "2023-12-04T11:00:00+03:00"
},
"valueQuantity" : {
"value" : 129,
"system" : "http://unitsofmeasure.org",
"code" : "kg"
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},
{
"sequence" : 5,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "pulse"
}
]
},
"timingPeriod" : {
"start" : "2023-12-04T10:00:00+03:00",
"end" : "2023-12-04T11:00:00+03:00"
},
"valueQuantity" : {
"value" : 100,
"system" : "http://unitsofmeasure.org",
"code" : "/min"
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},
{
"sequence" : 6,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "temperature"
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]
},
"timingPeriod" : {
"start" : "2023-12-04T10:00:00+03:00",
"end" : "2023-12-04T11:00:00+03:00"
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"valueQuantity" : {
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"code" : "Cel"
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},
{
"sequence" : 7,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "chief-complaint"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "28845006",
"display" : "Acute appendicitis with generalized peritonitis"
}
]
}
},
{
"sequence" : 8,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "oxygen-saturation"
}
]
},
"timingPeriod" : {
"start" : "2023-12-04T10:00:00+03:00",
"end" : "2023-12-04T11:00:00+03:00"
},
"valueQuantity" : {
"value" : 100,
"system" : "http://unitsofmeasure.org",
"code" : "%"
}
},
{
"sequence" : 9,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "respiratory-rate"
}
]
},
"timingPeriod" : {
"start" : "2023-12-04T10:00:00+03:00",
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{
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},
"valueQuantity" : {
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"system" : "http://unitsofmeasure.org",
"code" : "kg"
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},
{
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"category" : {
"coding" : [
{
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}
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},
"valueQuantity" : {
"value" : 1,
"system" : "http://unitsofmeasure.org",
"code" : "d"
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},
{
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"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "patient-history"
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},
"valueString" : "No systemic disease"
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{
"sequence" : 13,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "investigation-result"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/investigation-result",
"code" : "INP",
"display" : "Investigation(s) not performed"
}
]
}
},
{
"sequence" : 14,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "treatment-plan"
}
]
},
"valueString" : "Appendectomy"
},
{
"sequence" : 15,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "physical-examination"
}
]
},
"valueString" : "Stable"
},
{
"sequence" : 16,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "history-of-present-illness"
}
]
},
"valueString" : "No history"
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-am",
"code" : "K35.2",
"display" : "Acute appendicitis with generalized peritonitis"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/diagnosis-type",
"code" : "principal"
}
]
}
],
"onAdmission" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/diagnosis-on-admission",
"code" : "n",
"display" : "No"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/1334"
}
}
],
"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" : 0,
"currency" : "SAR"
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-payer-share",
"valueMoney" : {
"value" : 400,
"currency" : "SAR"
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-maternity",
"valueBoolean" : false
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-tax",
"valueMoney" : {
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"currency" : "SAR"
}
}
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