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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: Authorization Institutional Response #1 - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="483079"/>
  <meta>
    <profile
             value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ClaimResponse 483079</b></p><a name="483079"> </a><a name="hc483079"> </a><a name="483079-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-prior-auth-response.html">Nphies Authorization 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>Adjudication Reissue Reason</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/reissue-reason adjudication}">Additional adjudication</span></p><p><b>identifier</b>: <code>http://sni.com.sa/identifiers/claimresponse</code>/res_004512</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>: Preauthorization</p><p><b>patient</b>: <a href="Patient-173826788.html">Muhammad Khaled Abbas(official) Male, DoB: 2010-08-21 ( Permanent Resident Card Number: 2000000002)</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-b1b3432921324f97af3be9fd0b1a14ae.html">Organization Saudi General Hospital</a></p><p><b>request</b>: Identifier: <code>http://saudigeneralhospital.com.sa/identifiers/authorization</code>/req_1124856069</p><p><b>outcome</b>: Processing Complete</p><p><b>preAuthRef</b>: Auth_455433</p><p><b>preAuthPeriod</b>: 2023-12-04 --&gt; 2023-12-20</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>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>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><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>300</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>300</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><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-1334.html">Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000002; status = active; type = extended healthcare; relationship = Child; 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>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue">
    <valueCodeableConcept>
      <coding>
        <system
                value="http://nphies.sa/terminology/CodeSystem/reissue-reason"/>
        <code value="adjudication"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <identifier>
    <system value="http://sni.com.sa/identifiers/claimresponse"/>
    <value value="res_004512"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
    </coding>
  </type>
  <subType>
    <coding>
      <system value="http://nphies.sa/terminology/CodeSystem/claim-subtype"/>
      <code value="ip"/>
    </coding>
  </subType>
  <use value="preauthorization"/>
  <patient>🔗 
    <reference value="Patient/173826788"/>
  </patient>
  <created value="2023-12-05"/>
  <insurer>🔗 
    <reference value="Organization/bff3aa1fbd3648619ac082357bf135db"/>
  </insurer>
  <requestor>🔗 
    <reference value="Organization/b1b3432921324f97af3be9fd0b1a14ae"/>
  </requestor>
  <request>
    <type value="Claim"/>
    <identifier>
      <system
              value="http://saudigeneralhospital.com.sa/identifiers/authorization"/>
      <value value="req_1124856069"/>
    </identifier>
  </request>
  <outcome value="complete"/>
  <preAuthRef value="Auth_455433"/>
  <preAuthPeriod>
    <start value="2023-12-04"/>
    <end value="2023-12-20"/>
  </preAuthPeriod>
  <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>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="300"/>
        <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://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="300"/>
        <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>
  </item>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="eligible"/>
      </coding>
    </category>
    <amount>
      <value value="300"/>
      <currency value="SAR"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="benefit"/>
      </coding>
    </category>
    <amount>
      <value value="300"/>
      <currency value="SAR"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="copay"/>
      </coding>
    </category>
    <amount>
      <value value="0"/>
      <currency value="SAR"/>
    </amount>
  </total>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/1334"/>
    </coverage>
  </insurance>
</ClaimResponse>