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 Institutional Response #1 - JSON Representation
{
"resourceType" : "ClaimResponse",
"id" : "48100",
"meta" : {
"profile" : [
🔗 "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-response"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse 48100</b></p><a name=\"48100\"> </a><a name=\"hc48100\"> </a><a name=\"48100-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_683514</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>subType</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/claim-subtype ip}\">InPatient</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>: 2023-12-06</p><p><b>insurer</b>: <a href=\"Organization-bff3aa1fbd3648619ac082357bf135db.html\">Organization Saudi National Insurance</a></p><p><b>requestor</b>: <a href=\"Organization-b1b3432921324f97af3be9fd0b1a14ae.html\">Organization Saudi General Hospital</a></p><p><b>request</b>: Identifier: <code>http://saudigeneralhospital.com.sa/identifiers/claim</code>/req_3085</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://saudigeneralhospital.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>5000</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://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>5000</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>750</td><td>Saudi riyal</td></tr></table></blockquote></blockquote><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://saudigeneralhospital.com.sa/identifiers/patientInvoice</code>/Invc-20220120/IP-1110987</p><p><b>itemSequence</b>: 2</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>300</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://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>300</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>45</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>5300</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>5300</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>0</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>795</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>"
},
"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"
}
]
}
}
],
"identifier" : [
{
"system" : "http://sni.com.sa/identifiers/claimresponse",
"value" : "res_683514"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional"
}
]
},
"subType" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code" : "ip"
}
]
},
"use" : "claim",
"patient" : {
🔗 "reference" : "Patient/453"
},
"created" : "2023-12-06",
"insurer" : {
🔗 "reference" : "Organization/bff3aa1fbd3648619ac082357bf135db"
},
"requestor" : {
🔗 "reference" : "Organization/b1b3432921324f97af3be9fd0b1a14ae"
},
"request" : {
"type" : "Claim",
"identifier" : {
"system" : "http://saudigeneralhospital.com.sa/identifiers/claim",
"value" : "req_3085"
}
},
"outcome" : "complete",
"item" : [
{
"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-patientInvoice",
"valueIdentifier" : {
"system" : "http://saudigeneralhospital.com.sa/identifiers/patientInvoice",
"value" : "Invc-20220120/IP-1110987"
}
}
],
"itemSequence" : 1,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligible"
}
]
},
"amount" : {
"value" : 5000,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "copay"
}
]
},
"amount" : {
"value" : 0,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 5000,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code" : "approved-quantity"
}
]
},
"value" : 1
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "tax"
}
]
},
"amount" : {
"value" : 750,
"currency" : "SAR"
}
}
]
},
{
"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-patientInvoice",
"valueIdentifier" : {
"system" : "http://saudigeneralhospital.com.sa/identifiers/patientInvoice",
"value" : "Invc-20220120/IP-1110987"
}
}
],
"itemSequence" : 2,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligible"
}
]
},
"amount" : {
"value" : 300,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "copay"
}
]
},
"amount" : {
"value" : 0,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 300,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code" : "approved-quantity"
}
]
},
"value" : 1
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "tax"
}
]
},
"amount" : {
"value" : 45,
"currency" : "SAR"
}
}
]
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligible"
}
]
},
"amount" : {
"value" : 5300,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 5300,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "copay"
}
]
},
"amount" : {
"value" : 0,
"currency" : "SAR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "tax"
}
]
},
"amount" : {
"value" : 795,
"currency" : "SAR"
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/1985"
}
}
]
}