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 Oral Response #1 - XML Representation
<ClaimResponse xmlns="http://hl7.org/fhir">
<id value="293094"/>
<meta>
<profile
value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-response"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ClaimResponse 293094</b></p><a name="293094"> </a><a name="hc293094"> </a><a name="293094-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-claim-response.html">Nphies Claim Response</a></p></div><p><b>Adjudication Outcome</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/adjudication-outcome approved}">Approved</span></p><p><b>identifier</b>: <code>http://sni.com.sa/identifiers/claimresponse</code>/res_10411448401</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>: Claim</p><p><b>patient</b>: <a href="Patient-453.html">Sara Abbas Female, DoB: 1989-03-13 ( Permanent Resident Card Number: 2000000003)</a></p><p><b>created</b>: 2023-12-05</p><p><b>insurer</b>: <a href="Organization-bff3aa1fbd3648619ac082357bf135db.html">Organization Saudi National Insurance</a></p><p><b>requestor</b>: <a href="Organization-215.html">Organization Saudi Dental Clinic</a></p><p><b>request</b>: Identifier: <code>http://saudidentalclinic.com.sa/identifiers/claim</code>/req_29309905401</p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>item</b></p><p><b>Adjudication Outcome</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/adjudication-outcome approved}">Approved</span></p><p><b>Patient Invoice</b>: <code>http://saudidentalclinic.com.sa/identifiers/patientInvoice</code>/Invc-20220120/IP-1110987</p><p><b>itemSequence</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>230</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>20</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>210</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><p><b>value</b>: 1</p></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>31.5</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 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>230</td><td>Saudi riyal</td></tr></table></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><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>210</td><td>Saudi riyal</td></tr></table></blockquote><blockquote><p><b>total</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>20</td><td>Saudi riyal</td></tr></table></blockquote><blockquote><p><b>total</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>31.5</td><td>Saudi riyal</td></tr></table></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-1985.html">Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000003; status = active; type = extended healthcare; relationship = Spouse; network = Golden C</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>
<identifier>
<system value="http://sni.com.sa/identifiers/claimresponse"/>
<value value="res_10411448401"/>
</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="claim"/>
<patient>🔗
<reference value="Patient/453"/>
</patient>
<created value="2023-12-05"/>
<insurer>🔗
<reference value="Organization/bff3aa1fbd3648619ac082357bf135db"/>
</insurer>
<requestor>🔗
<reference value="Organization/215"/>
</requestor>
<request>
<identifier>
<system value="http://saudidentalclinic.com.sa/identifiers/claim"/>
<value value="req_29309905401"/>
</identifier>
</request>
<outcome value="complete"/>
<item>
<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-patientInvoice">
<valueIdentifier>
<system
value="http://saudidentalclinic.com.sa/identifiers/patientInvoice"/>
<value value="Invc-20220120/IP-1110987"/>
</valueIdentifier>
</extension>
<itemSequence value="1"/>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="230"/>
<currency value="SAR"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
</coding>
</category>
<amount>
<value value="20"/>
<currency value="SAR"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="210"/>
<currency value="SAR"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/ksa-adjudication"/>
<code value="approved-quantity"/>
</coding>
</category>
<value value="1"/>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="tax"/>
</coding>
</category>
<amount>
<value value="31.5"/>
<currency value="SAR"/>
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="230"/>
<currency value="SAR"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="210"/>
<currency value="SAR"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="copay"/>
</coding>
</category>
<amount>
<value value="20"/>
<currency value="SAR"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="tax"/>
</coding>
</category>
<amount>
<value value="31.5"/>
<currency value="SAR"/>
</amount>
</total>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/1985"/>
</coverage>
</insurance>
</ClaimResponse>