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

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: Advanced Authorization example #1 - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="142298"/>
  <meta>
    <profile
             value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/advanced-authorization"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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 --&gt; 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>
  </text>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome">
    <valueCodeableConcept>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/adjudication-outcome"/>
        <code value="approved"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-advancedAuth-reason">
    <valueCodeableConcept>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/advancedAuth-reason"/>
        <code value="referral"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-newborn">
    <valueBoolean value="false"/>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-serviceProvider">
    <valueReference>
      <reference
                 value="http://sni.com.sa/Organization/b1b3432921324f97af3be9fd0b1a14ae"/>
    </valueReference>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-referringProvider">
    <valueReference>
      <display value="Dr. Test Doctor outside npies (wave3)"/>
    </valueReference>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
      <valuePositiveInt value="1"/>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
          <code value="info"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString">
      <valueString
                   value="Advanced authorization for providing mentioned services to the patient"/>
    </extension>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis">
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-sequence">
      <valuePositiveInt value="2"/>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-diagnosisCodeableConcept">
      <valueCodeableConcept>
        <coding>
          <system value="http://hl7.org/fhir/sid/icd-10-am"/>
          <code value="V49.4"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-type">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://nphies.sa/terminology/CodeSystem/diagnosis-type"/>
          <code value="secondary"/>
        </coding>
      </valueCodeableConcept>
    </extension>
  </extension>
  <identifier>
    <system value="http://sni.com.sa/identifiers/advanced-priorauth"/>
    <value value="AdvAuth-300982300"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="oral"/>
    </coding>
  </type>
  <subType>
    <coding>
      <system value="http://nphies.sa/terminology/CodeSystem/claim-subtype"/>
      <code value="op"/>
    </coding>
  </subType>
  <use value="preauthorization"/>
  <patient>
    <reference value="http://sni.com.sa/Patient/123454186"/>
  </patient>
  <created value="2022-07-18"/>
  <insurer>
    <reference
               value="http://sni.com.sa/Organization/bff3aa1fbd3648619ac082357bf135db"/>
  </insurer>
  <outcome value="complete"/>
  <preAuthRef value="AdAuth-150123-1530"/>
  <preAuthPeriod>
    <start value="2022-09-15T18:10:44.732+00:00"/>
    <end value="2022-10-15T18:10:44.732+00:00"/>
  </preAuthPeriod>
  <addItem>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-maternity">
      <valueBoolean value="false"/>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://nphies.sa/terminology/CodeSystem/adjudication-outcome"/>
          <code value="approved"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-sequence">
      <valuePositiveInt value="1"/>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-informationSequence">
      <valuePositiveInt value="1"/>
    </extension>
    <extension
               url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-package">
      <valueBoolean value="false"/>
    </extension>
    <productOrService>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/oral-health-op"/>
        <code value="658"/>
      </coding>
    </productOrService>
    <quantity>
      <value value="1"/>
    </quantity>
    <bodySite>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/fdi-oral-region"/>
        <code value="25"/>
      </coding>
    </bodySite>
    <subSite>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/fdi-tooth-surface"/>
        <code value="V"/>
      </coding>
    </subSite>
    <noteNumber value="1"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="100"/>
        <currency value="SAR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <currency value="SAR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://nphies.sa/terminology/CodeSystem/ksa-adjudication"/>
          <code value="approved-quantity"/>
        </coding>
      </category>
      <amount>
        <value value="1"/>
        <currency value="SAR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="tax"/>
        </coding>
      </category>
      <amount>
        <value value="15"/>
        <currency value="SAR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="100"/>
        <currency value="SAR"/>
      </amount>
    </adjudication>
  </addItem>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="benefit"/>
      </coding>
    </category>
    <amount>
      <value value="100"/>
    </amount>
  </total>
  <processNote>
    <number value="1"/>
    <type value="display"/>
    <text
          value="Process Note Text to give more general information or direction"/>
  </processNote>
  <insurance>
    <sequence value="1"/>
    <focal value="false"/>
    <coverage>
      <reference value="http://sni.com.sa/Coverage/1333"/>
    </coverage>
  </insurance>
</ClaimResponse>