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 Institutional Request #1 - XML Representation
<Claim xmlns="http://hl7.org/fhir">
<id value="483070"/>
<meta>
<profile
value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/institutional-claim"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim 483070</b></p><a name="483070"> </a><a name="hc483070"> </a><a name="483070-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-claim.html">Nphies Claim Institutional</a></p></div><p><b>Encounter</b>: <a href="Bundle-a84aabfa-1163-407d-aa38-f8119a0b8888.html#http-//saudigeneralhospital.com.sa/Encounter/10130">Bundle: type = message; timestamp = 2023-12-05 09:20:15+0300</a></p><p><b>Eligibility Offline Reference</b>: EligResp-31212432</p><p><b>Eligibility Offline Date</b>: 2023-12-05</p><p><b>Episode</b>: <code>http://saudigeneralhospital.com.sa/identifiers/episode</code>/provider_EpisodeID_48903211</p><p><b>identifier</b>: <code>http://saudigeneralhospital.com.sa/identifiers/claim</code>/req_3085</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>: Claim</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>: 2023-12-05 12:30:15+0300</p><p><b>insurer</b>: <a href="Organization-bff3aa1fbd3648619ac082357bf135db.html">Organization Saudi National Insurance</a></p><p><b>provider</b>: <a href="Organization-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>: 2023-12-05 12:30:15+0300 --> 2023-12-05 12:30:15+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 12:30:15+0300 --> 2023-12-05 12:30:15+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 12:30:15+0300 --> 2023-12-05 12:30:15+0300</p><p><b>value</b>: 175 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 12:30:15+0300 --> 2023-12-05 12:30:15+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>: 2023-12-05 12:30:15+0300 --> 2023-12-05 12:30:15+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 12:30:15+0300 --> 2023-12-05 12:30:15+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 12:30:15+0300 --> 2023-12-05 12:30:15+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 12:30:15+0300 --> 2023-12-05 12:30:15+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 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 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>: 12</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>: 13</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>: Surgery</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 physical-examination}">Physical Examination</span></p><p><b>value</b>: Stable</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 history-of-present-illness}">history Of Present Illness</span></p><p><b>value</b>: No history</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 onset}">Onset</span></p><p><b>code</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-am R07.1}">Chest pain on breathing</span></p><p><b>timing</b>: 2023-12-05</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 17</p><p><b>category</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category ventilation-hours}">Ventilation Hours</span></p><p><b>timing</b>: 2023-12-05 12:30:15+0300 --> 2023-12-05 12:30:15+0300</p><p><b>value</b>: 1.5 h<span style="background: LightGoldenRodYellow"> (Details: UCUM codeh = 'h')</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>Condition Onset</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/condition-onset NR}">Not reported</span></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-am I48.2}">Chronic atrial fibrillation</span></p><p><b>type</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-type principal}">Principal Diagnosis</span></p><p><b>onAdmission</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-on-admission y}">Yes</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>Condition Onset</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/condition-onset NR}">Not reported</span></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-am R51}">Headache</span></p><p><b>type</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-type secondary}">Secondary Diagnosis</span></p><p><b>onAdmission</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-on-admission y}">Yes</span></p></blockquote><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>Tax</b>: <span title="Saudi Riyal">SAR750.00</span> (SAR)</p><p><b>Patient Share</b>: <span title="Saudi Riyal">SAR0.00</span> (SAR)</p><p><b>Patient Invoice</b>: <code>http://saudigeneralhospital.com.sa/identifiers/patientInvoice</code>/Invc-20220120/IP-1110987</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>informationSequence</b>: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17</p><p><b>productOrService</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/procedures 38287-02-00}">Catheter ablation of arrhythmia circuit or focus involving left atrial chamber</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>5000</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>5750</td><td>Saudi riyal</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>Package Code</b>: false</p><p><b>Tax</b>: <span title="Saudi Riyal">SAR45.00</span> (SAR)</p><p><b>Patient Share</b>: <span title="Saudi Riyal">SAR0.00</span> (SAR)</p><p><b>Patient Invoice</b>: <code>http://saudigeneralhospital.com.sa/identifiers/patientInvoice</code>/Invc-20220120/IP-1110987</p><p><b>Maternity</b>: false</p><p><b>sequence</b>: 2</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, 17</p><p><b>productOrService</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/procedures 13882-00-00}">Management of continuous ventilatory support, <= 24 hours</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>345</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>6095</td><td>Saudi riyal</td></tr></table></div>
</text>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-encounter">
<valueReference>
<reference value="http://saudigeneralhospital.com.sa/Encounter/10130"/>
</valueReference>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-eligibility-offline-reference">
<valueString value="EligResp-31212432"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-eligibility-offline-date">
<valueDateTime value="2023-12-05"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-episode">
<valueIdentifier>
<system value="http://saudigeneralhospital.com.sa/identifiers/episode"/>
<value value="provider_EpisodeID_48903211"/>
</valueIdentifier>
</extension>
<identifier>
<system value="http://saudigeneralhospital.com.sa/identifiers/claim"/>
<value value="req_3085"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="institutional"/>
</coding>
</type>
<subType>
<coding>
<system value="http://nphies.sa/terminology/CodeSystem/claim-subtype"/>
<code value="ip"/>
</coding>
</subType>
<use value="claim"/>
<patient>🔗
<reference value="Patient/173826788"/>
</patient>
<created value="2023-12-05T12:30:15.23+03:00"/>
<insurer>🔗
<reference value="Organization/bff3aa1fbd3648619ac082357bf135db"/>
</insurer>
<provider>🔗
<reference value="Organization/b1b3432921324f97af3be9fd0b1a14ae"/>
</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/1"/>
</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="08.26"/>
</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="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+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="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+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="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="175"/>
<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="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="129"/>
<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="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+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="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+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="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+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="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+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="admission-weight"/>
</coding>
</category>
<valueQuantity>
<value value="129"/>
<system value="http://unitsofmeasure.org"/>
<code value="kg"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="11"/>
<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="12"/>
<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="13"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="treatment-plan"/>
</coding>
</category>
<valueString value="Surgery"/>
</supportingInfo>
<supportingInfo>
<sequence value="14"/>
<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="15"/>
<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>
<supportingInfo>
<sequence value="16"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="onset"/>
</coding>
</category>
<code>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-am"/>
<code value="R07.1"/>
</coding>
<text value="Chest pain on breathing"/>
</code>
<timingDate value="2023-12-05"/>
</supportingInfo>
<supportingInfo>
<sequence value="17"/>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="ventilation-hours"/>
</coding>
</category>
<timingPeriod>
<start value="2023-12-05T12:30:15.23+03:00"/>
<end value="2023-12-05T12:30:15.23+03:00"/>
</timingPeriod>
<valueQuantity>
<value value="1.5"/>
<system value="http://unitsofmeasure.org"/>
<code value="h"/>
</valueQuantity>
</supportingInfo>
<diagnosis>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-condition-onset">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/condition-onset"/>
<code value="NR"/>
</coding>
</valueCodeableConcept>
</extension>
<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>
<onAdmission>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/diagnosis-on-admission"/>
<code value="y"/>
</coding>
</onAdmission>
</diagnosis>
<diagnosis>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-condition-onset">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/condition-onset"/>
<code value="NR"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="2"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-am"/>
<code value="R51"/>
<display value="Headache"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/diagnosis-type"/>
<code value="secondary"/>
</coding>
</type>
<onAdmission>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/diagnosis-on-admission"/>
<code value="y"/>
</coding>
</onAdmission>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/1334"/>
</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="750"/>
<currency value="SAR"/>
</valueMoney>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-share">
<valueMoney>
<value value="0"/>
<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>
<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"/>
<informationSequence value="1"/>
<informationSequence value="2"/>
<informationSequence value="3"/>
<informationSequence value="4"/>
<informationSequence value="5"/>
<informationSequence value="6"/>
<informationSequence value="7"/>
<informationSequence value="8"/>
<informationSequence value="9"/>
<informationSequence value="10"/>
<informationSequence value="11"/>
<informationSequence value="12"/>
<informationSequence value="13"/>
<informationSequence value="14"/>
<informationSequence value="15"/>
<informationSequence value="16"/>
<informationSequence value="17"/>
<productOrService>
<coding>
<system value="http://nphies.sa/terminology/CodeSystem/procedures"/>
<code value="38287-02-00"/>
<display
value="Catheter ablation of arrhythmia circuit or focus involving left atrial chamber"/>
</coding>
</productOrService>
<servicedDate value="2023-12-05"/>
<quantity>
<value value="1"/>
</quantity>
<unitPrice>
<value value="5000"/>
<currency value="SAR"/>
</unitPrice>
<net>
<value value="5750"/>
<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-tax">
<valueMoney>
<value value="45"/>
<currency value="SAR"/>
</valueMoney>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-share">
<valueMoney>
<value value="0"/>
<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>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-maternity">
<valueBoolean value="false"/>
</extension>
<sequence value="2"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<informationSequence value="1"/>
<informationSequence value="2"/>
<informationSequence value="3"/>
<informationSequence value="4"/>
<informationSequence value="5"/>
<informationSequence value="6"/>
<informationSequence value="7"/>
<informationSequence value="8"/>
<informationSequence value="9"/>
<informationSequence value="10"/>
<informationSequence value="11"/>
<informationSequence value="12"/>
<informationSequence value="13"/>
<informationSequence value="14"/>
<informationSequence value="15"/>
<informationSequence value="16"/>
<informationSequence value="17"/>
<productOrService>
<coding>
<system value="http://nphies.sa/terminology/CodeSystem/procedures"/>
<code value="13882-00-00"/>
<display
value="Management of continuous ventilatory support, <= 24 hours"/>
</coding>
</productOrService>
<servicedDate value="2023-12-04"/>
<quantity>
<value value="1"/>
</quantity>
<unitPrice>
<value value="300"/>
<currency value="SAR"/>
</unitPrice>
<net>
<value value="345"/>
<currency value="SAR"/>
</net>
</item>
<total>
<value value="6095"/>
<currency value="SAR"/>
</total>
</Claim>