Claim Institutional Response #1 - Healthcare Financial Services IG Edition 1 v0.3.0

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

Example ClaimResponse: Claim Institutional Response #1

Generated Narrative: ClaimResponse 48100

Profile: Nphies Claim Response

Adjudication Outcome: Approved

identifier: http://sni.com.sa/identifiers/claimresponse/res_683514

status: Active

type: Institutional

subType: InPatient

use: Claim

patient: Sara Abbas Female, DoB: 1989-03-13 ( Permanent Resident Card Number: 2000000003)

created: 2023-12-06

insurer: Organization Saudi National Insurance

requestor: Organization Saudi General Hospital

request: Identifier: http://saudigeneralhospital.com.sa/identifiers/claim/req_3085

outcome: Processing Complete

item
Adjudication Outcome: Approved
Patient Invoice: http://saudigeneralhospital.com.sa/identifiers/patientInvoice/Invc-20220120/IP-1110987
itemSequence: 1
adjudication
category: Eligible Amount
Amounts
- Value Currency
* 5000 Saudi riyal
adjudication
category: CoPay
Amounts
- Value Currency
* 0 Saudi riyal
adjudication
category: Benefit Amount
Amounts
- Value Currency
* 5000 Saudi riyal
adjudication
category: Approved Quantity
value: 1
adjudication
category: Tax
Amounts
- Value Currency
* 750 Saudi riyal

item
Adjudication Outcome: Approved
Patient Invoice: http://saudigeneralhospital.com.sa/identifiers/patientInvoice/Invc-20220120/IP-1110987
itemSequence: 2
adjudication
category: Eligible Amount
Amounts
- Value Currency
* 300 Saudi riyal
adjudication
category: CoPay
Amounts
- Value Currency
* 0 Saudi riyal
adjudication
category: Benefit Amount
Amounts
- Value Currency
* 300 Saudi riyal
adjudication
category: Approved Quantity
value: 1
adjudication
category: Tax
Amounts
- Value Currency
* 45 Saudi riyal

total
category: Eligible Amount
Amounts
- Value Currency
* 5300 Saudi riyal

total
category: Benefit Amount
Amounts
- Value Currency
* 5300 Saudi riyal

total
category: CoPay
Amounts
- Value Currency
* 0 Saudi riyal

total
category: Tax
Amounts
- Value Currency
* 795 Saudi riyal

Insurances

Sequence

Focal

Coverage

true

Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000003; status = active; type = extended healthcare; relationship = Spouse; network = Golden C