Claim Pharmacy Request #1 - XML Representation - Healthcare Financial Services IG Edition 1 v0.3.0

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: Claim Pharmacy Request #1 - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <id value="483078"/>
  <meta>
    <profile
             value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/pharmacy-claim"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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 --&gt; 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>
  </text>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier">
    <valueIdentifier>
      <system value="http://saudicentralpharmacy.sa.com/identifiers/batch"/>
      <value value="123456787879zxc2345678ujh"/>
    </valueIdentifier>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number">
    <valuePositiveInt value="1"/>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period">
    <valuePeriod>
      <start value="2023-12-06"/>
      <end value="2023-12-06"/>
    </valuePeriod>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-authorization-offline-date">
    <valueDateTime value="2023-12-05T11:05:48+03:00"/>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-episode">
    <valueIdentifier>
      <system value="http://saudicentralpharmacy.sa.com/identifiers/episode"/>
      <value value="EpisodeID-209-0120"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="http://saudicentralpharmacy.sa.com/identifiers/claim"/>
    <value value="req_1902483080"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="pharmacy"/>
    </coding>
  </type>
  <subType>
    <coding>
      <system value="http://nphies.sa/terminology/CodeSystem/claim-subtype"/>
      <code value="op"/>
    </coding>
  </subType>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/123454186"/>
  </patient>
  <created value="2023-12-05T09:20:15.23+03:00"/>
  <insurer>🔗 
    <reference value="Organization/bff3aa1fbd3648619ac082357bf135db"/>
  </insurer>
  <provider>🔗 
    <reference value="Organization/6025"/>
  </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>
  <supportingInfo>
    <sequence value="1"/>
    <category>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
        <code value="days-supply"/>
      </coding>
    </category>
    <valueQuantity>
      <value value="30"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="d"/>
    </valueQuantity>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-am"/>
        <code value="B34.9"/>
        <display value="Viral infection, unspecified"/>
      </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/1333"/>
    </coverage>
    <preAuthRef value="Pseudo-payer-Portal-Auth-02"/>
  </insurance>
  <item>
    <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-package">
      <valueBoolean value="false"/>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-tax">
      <valueMoney>
        <value value="9"/>
        <currency value="SAR"/>
      </valueMoney>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice">
      <valueIdentifier>
        <system
                value="http://saudicentralpharmacy.sa.com/identifiers/patientInvoice"/>
        <value value="Invc-20220120-90408"/>
      </valueIdentifier>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-prescribed-Medication">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://nphies.sa/terminology/CodeSystem/medication-codes"/>
          <code value="06285096001627"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-pharmacist-Selection-Reason">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://nphies.sa/terminology/CodeSystem/pharmacist-selection-reason"/>
          <code value="patient-request"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-maternity">
      <valueBoolean value="false"/>
    </extension>
    <sequence value="1"/>
    <diagnosisSequence value="1"/>
    <informationSequence value="1"/>
    <productOrService>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/medication-codes"/>
        <code value="06285096001627"/>
        <display value="RELENZA 5MG POWDER FOR INHALATION"/>
      </coding>
    </productOrService>
    <servicedDate value="2023-12-04"/>
    <quantity>
      <value value="1"/>
    </quantity>
    <unitPrice>
      <value value="60"/>
      <currency value="SAR"/>
    </unitPrice>
    <net>
      <value value="69"/>
      <currency value="SAR"/>
    </net>
  </item>
  <total>
    <value value="69"/>
    <currency value="SAR"/>
  </total>
</Claim>