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 Pharmacy Request #1 - JSON Representation
{
"resourceType" : "Claim",
"id" : "483078",
"meta" : {
"profile" : [
🔗 "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/pharmacy-claim"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim 483078</b></p><a name=\"483078\"> </a><a name=\"hc483078\"> </a><a name=\"483078-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-pharmacy-claim.html\">Nphies Claim Pharmacy</a></p></div><p><b>Claim Batch Identifier</b>: <code>http://saudicentralpharmacy.sa.com/identifiers/batch</code>/123456787879zxc2345678ujh</p><p><b>Claim Batch Number</b>: 1</p><p><b>Claim Batch Period</b>: 2023-12-06 --> 2023-12-06</p><p><b>Authorization Offline Date</b>: 2023-12-05 11:05:48+0300</p><p><b>Episode</b>: <code>http://saudicentralpharmacy.sa.com/identifiers/episode</code>/EpisodeID-209-0120</p><p><b>identifier</b>: <code>http://saudicentralpharmacy.sa.com/identifiers/claim</code>/req_1902483080</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type pharmacy}\">Pharmacy</span></p><p><b>subType</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/claim-subtype op}\">OutPatient</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-123454186.html\">Ahmad Khaled Abbas(official) Male, DoB: 1984-12-25 ( Passport Number: G12345678)</a></p><p><b>created</b>: 2023-12-05 09:20:15+0300</p><p><b>insurer</b>: <a href=\"Organization-bff3aa1fbd3648619ac082357bf135db.html\">Organization Saudi National Insurance</a></p><p><b>provider</b>: <a href=\"Organization-6025.html\">Organization Saudi Pharmacy</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>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category days-supply}\">Days Supply</span></td><td>30 d<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM coded = 'd')</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 B34.9}\">Viral infection, unspecified</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-1333.html\">Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000001; status = active; type = extended healthcare; dependent = 01; relationship = Self; network = Golden C</a></td><td>Pseudo-payer-Portal-Auth-02</td></tr></table><blockquote><p><b>item</b></p><p><b>Patient Share</b>: <span title=\"Saudi Riyal\">SAR0.00</span> (SAR)</p><p><b>Package Code</b>: false</p><p><b>Tax</b>: <span title=\"Saudi Riyal\">SAR9.00</span> (SAR)</p><p><b>Patient Invoice</b>: <code>http://saudicentralpharmacy.sa.com/identifiers/patientInvoice</code>/Invc-20220120-90408</p><p><b>Prescribed Medication</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/medication-codes 06285096001627}\">06285096001627</span></p><p><b>Pharmacist Selection Reason</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/pharmacist-selection-reason patient-request}\">patient request</span></p><p><b>Maternity</b>: false</p><p><b>sequence</b>: 1</p><p><b>diagnosisSequence</b>: 1</p><p><b>informationSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/medication-codes 06285096001627}\">RELENZA 5MG POWDER FOR INHALATION</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>60</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>69</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>69</td><td>Saudi riyal</td></tr></table></div>"
},
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier" : {
"system" : "http://saudicentralpharmacy.sa.com/identifiers/batch",
"value" : "123456787879zxc2345678ujh"
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number",
"valuePositiveInt" : 1
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period",
"valuePeriod" : {
"start" : "2023-12-06",
"end" : "2023-12-06"
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-authorization-offline-date",
"valueDateTime" : "2023-12-05T11:05:48+03:00"
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-episode",
"valueIdentifier" : {
"system" : "http://saudicentralpharmacy.sa.com/identifiers/episode",
"value" : "EpisodeID-209-0120"
}
}
],
"identifier" : [
{
"system" : "http://saudicentralpharmacy.sa.com/identifiers/claim",
"value" : "req_1902483080"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "pharmacy"
}
]
},
"subType" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code" : "op"
}
]
},
"use" : "claim",
"patient" : {
🔗 "reference" : "Patient/123454186"
},
"created" : "2023-12-05T09:20:15.23+03:00",
"insurer" : {
🔗 "reference" : "Organization/bff3aa1fbd3648619ac082357bf135db"
},
"provider" : {
🔗 "reference" : "Organization/6025"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"payee" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}
]
}
},
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "days-supply"
}
]
},
"valueQuantity" : {
"value" : 30,
"system" : "http://unitsofmeasure.org",
"code" : "d"
}
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-am",
"code" : "B34.9",
"display" : "Viral infection, unspecified"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/diagnosis-type",
"code" : "principal"
}
]
}
]
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/1333"
},
"preAuthRef" : [
"Pseudo-payer-Portal-Auth-02"
]
}
],
"item" : [
{
"extension" : [
{
"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-package",
"valueBoolean" : false
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-tax",
"valueMoney" : {
"value" : 9,
"currency" : "SAR"
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier" : {
"system" : "http://saudicentralpharmacy.sa.com/identifiers/patientInvoice",
"value" : "Invc-20220120-90408"
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-prescribed-Medication",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/medication-codes",
"code" : "06285096001627"
}
]
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-pharmacist-Selection-Reason",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/pharmacist-selection-reason",
"code" : "patient-request"
}
]
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-maternity",
"valueBoolean" : false
}
],
"sequence" : 1,
"diagnosisSequence" : [
1
],
"informationSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/medication-codes",
"code" : "06285096001627",
"display" : "RELENZA 5MG POWDER FOR INHALATION"
}
]
},
"servicedDate" : "2023-12-04",
"quantity" : {
"value" : 1
},
"unitPrice" : {
"value" : 60,
"currency" : "SAR"
},
"net" : {
"value" : 69,
"currency" : "SAR"
}
}
],
"total" : {
"value" : 69,
"currency" : "SAR"
}
}