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
: Advanced Authorization example #1 - JSON Representation
{
"resourceType" : "ClaimResponse",
"id" : "142298",
"meta" : {
"profile" : [
🔗 "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/advanced-authorization"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse 142298</b></p><a name=\"142298\"> </a><a name=\"hc142298\"> </a><a name=\"142298-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-advanced-authorization.html\">Nphies Advanced Authorization</a></p></div><p><b>Adjudication Outcome</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/adjudication-outcome approved}\">Approved</span></p><p><b>Advanced Auth Reason Extension</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/advancedAuth-reason referral}\">Referral</span></p><p><b>Newborn</b>: false</p><p><b>Service Provider Extension</b>: <a href=\"Bundle-c2c63768-a65b-4784-ab91-6c09012c3abd.html#http-//sni.com.sa/Organization/b1b3432921324f97af3be9fd0b1a14ae\">Bundle: type = message; timestamp = 2023-12-04 13:39:58+0000</a></p><p><b>Referring Provider Extension</b>: Dr. Test Doctor outside npies (wave3)</p><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 1</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category info}\">Information</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: Advanced authorization for providing mentioned services to the patient</li></ul></blockquote><blockquote><p><b>Diagnosis Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-sequence: 2</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-diagnosisCodeableConcept: <span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-am V49.4}\">V49.4</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-type: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-type secondary}\">Secondary Diagnosis</span></li></ul></blockquote><p><b>identifier</b>: <code>http://sni.com.sa/identifiers/advanced-priorauth</code>/AdvAuth-300982300</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=\"Bundle-43c68545-8e37-4744-b8ea-9a1e3c1ada84.html#http-//sni.com.sa/Patient/123454186\">Bundle: type = message; timestamp = 2023-12-19 08:20:29+0000</a></p><p><b>created</b>: 2022-07-18</p><p><b>insurer</b>: <a href=\"Bundle-43c68545-8e37-4744-b8ea-9a1e3c1ada84.html#http-//sni.com.sa/Organization/bff3aa1fbd3648619ac082357bf135db\">Bundle: type = message; timestamp = 2023-12-19 08:20:29+0000</a></p><p><b>outcome</b>: Processing Complete</p><p><b>preAuthRef</b>: AdAuth-150123-1530</p><p><b>preAuthPeriod</b>: 2022-09-15 18:10:44+0000 --> 2022-10-15 18:10:44+0000</p><blockquote><p><b>addItem</b></p><p><b>Maternity</b>: false</p><p><b>Adjudication Outcome</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/adjudication-outcome approved}\">Approved</span></p><p><b>Sequence Extension</b>: 1</p><p><b>Information Sequence Extension</b>: 1</p><p><b>Package Code</b>: false</p><p><b>productOrService</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/oral-health-op 658}\">The extraoral repair of a crown, bridge or splint.</span></p><p><b>quantity</b>: 1</p><p><b>bodySite</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/fdi-oral-region 25}\">UPPER LEFT; PERMANENT TEETH # 5</span></p><p><b>subSite</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/fdi-tooth-surface V}\">Ventral</span></p><p><b>noteNumber</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible Amount</span></p><h3>Amounts</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>100</td><td>Saudi riyal</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication copay}\">CoPay</span></p><h3>Amounts</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>0</td><td>Saudi riyal</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/ksa-adjudication approved-quantity}\">Approved Quantity</span></p><h3>Amounts</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>1</td><td>Saudi riyal</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication tax}\">Tax</span></p><h3>Amounts</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>15</td><td>Saudi riyal</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Benefit Amount</span></p><h3>Amounts</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>100</td><td>Saudi riyal</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Benefit Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td>100</td></tr></table></blockquote><h3>ProcessNotes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Number</b></td><td><b>Type</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>Display</td><td>Process Note Text to give more general information or direction</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>false</td><td><a href=\"Bundle-43c68545-8e37-4744-b8ea-9a1e3c1ada84.html#http-//sni.com.sa/Coverage/1333\">Bundle: type = message; timestamp = 2023-12-19 08:20:29+0000</a></td></tr></table></div>"
},
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code" : "approved"
}
]
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-advancedAuth-reason",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/advancedAuth-reason",
"code" : "referral"
}
]
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-newborn",
"valueBoolean" : false
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-serviceProvider",
"valueReference" : {
"reference" : "http://sni.com.sa/Organization/b1b3432921324f97af3be9fd0b1a14ae"
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-referringProvider",
"valueReference" : {
"display" : "Dr. Test Doctor outside npies (wave3)"
}
},
{
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence",
"valuePositiveInt" : 1
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code" : "info"
}
]
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString",
"valueString" : "Advanced authorization for providing mentioned services to the patient"
}
],
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo"
},
{
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-sequence",
"valuePositiveInt" : 2
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-diagnosisCodeableConcept",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-am",
"code" : "V49.4"
}
]
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/diagnosis-type",
"code" : "secondary"
}
]
}
}
],
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis"
}
],
"identifier" : [
{
"system" : "http://sni.com.sa/identifiers/advanced-priorauth",
"value" : "AdvAuth-300982300"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "oral"
}
]
},
"subType" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code" : "op"
}
]
},
"use" : "preauthorization",
"patient" : {
"reference" : "http://sni.com.sa/Patient/123454186"
},
"created" : "2022-07-18",
"insurer" : {
"reference" : "http://sni.com.sa/Organization/bff3aa1fbd3648619ac082357bf135db"
},
"outcome" : "complete",
"preAuthRef" : "AdAuth-150123-1530",
"preAuthPeriod" : {
"start" : "2022-09-15T18:10:44.732+00:00",
"end" : "2022-10-15T18:10:44.732+00:00"
},
"addItem" : [
{
"extension" : [
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-maternity",
"valueBoolean" : false
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code" : "approved"
}
]
}
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-sequence",
"valuePositiveInt" : 1
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-informationSequence",
"valuePositiveInt" : 1
},
{
"url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-package",
"valueBoolean" : false
}
],
"productOrService" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/oral-health-op",
"code" : "658"
}
]
},
"quantity" : {
"value" : 1
},
"bodySite" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/fdi-oral-region",
"code" : "25"
}
]
},
"subSite" : [
{
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/fdi-tooth-surface",
"code" : "V"
}
]
}
],
"noteNumber" : [
1
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligible"
}
]
},
"amount" : {
"value" : 100,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "copay"
}
]
},
"amount" : {
"value" : 0,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code" : "approved-quantity"
}
]
},
"amount" : {
"value" : 1,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "tax"
}
]
},
"amount" : {
"value" : 15,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 100,
"currency" : "SAR"
}
}
]
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 100
}
}
],
"processNote" : [
{
"number" : 1,
"type" : "display",
"text" : "Process Note Text to give more general information or direction"
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : false,
"coverage" : {
"reference" : "http://sni.com.sa/Coverage/1333"
}
}
]
}