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 Oral Response #1 - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "618042",
  "meta" : {
    "profile" : [
      🔗 "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|0.3.0"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse 618042</b></p><a name=\"618042\"> </a><a name=\"hc618042\"> </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 Responseversion: null0.3.0)</a></p></div><p><b>Adjudication Outcome</b>: <span title=\"Codes:{http://nphies.sa/terminology/CodeSystem/adjudication-outcome approved}\">Approved</span></p><p><b>Transfer Authorization Number</b>: GHD517</p><p><b>Transfer Authorization Period</b>: 2021-10-10 --&gt; 2021-10-12</p><p><b>Transfer Authorization Provider</b>: <a href=\"Organization-bff3aa1fbd3648619ac082357bf135ab.html\">Organization Test Provider 2</a></p><p><b>identifier</b>: <code>http://sni.com.sa/identifiers/claimresponse</code>/resp_618044</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=\"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/authorization</code>/req_293093</p><p><b>outcome</b>: Processing Complete</p><p><b>preAuthRef</b>: PLJ9147</p><p><b>preAuthPeriod</b>: 2021-10-10 --&gt; 2021-10-12</p><p><b>payeeType</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}\">Provider</span></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><p><b>noteNumber</b>: 1</p><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 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>0</td><td>Saudi riyal</td></tr></table></blockquote></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>Print (Form)</td><td>Referral to Test Provider 2, authorization #GHD517, for Root Canal</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>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"
          }
        ]
      }
    },
    {
      "url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-transferAuthorizationNumber",
      "valueString" : "GHD517"
    },
    {
      "url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-transferAuthorizationPeriod",
      "valuePeriod" : {
        "start" : "2021-10-10",
        "end" : "2021-10-12"
      }
    },
    {
      "url" : "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-transferAuthorizationProvider",
      "valueReference" : {
        🔗 "reference" : "Organization/bff3aa1fbd3648619ac082357bf135ab"
      }
    }
  ],
  "identifier" : [
    {
      "system" : "http://sni.com.sa/identifiers/claimresponse",
      "value" : "resp_618044"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "oral"
      }
    ]
  },
  "subType" : {
    "coding" : [
      {
        "system" : "http://nphies.sa/terminology/CodeSystem/claim-subtype",
        "code" : "op"
      }
    ]
  },
  "use" : "preauthorization",
  "patient" : {
    🔗 "reference" : "Patient/453"
  },
  "created" : "2023-12-05",
  "insurer" : {
    🔗 "reference" : "Organization/bff3aa1fbd3648619ac082357bf135db"
  },
  "requestor" : {
    🔗 "reference" : "Organization/215"
  },
  "request" : {
    "identifier" : {
      "system" : "http://saudidentalclinic.com.sa/identifiers/authorization",
      "value" : "req_293093"
    }
  },
  "outcome" : "complete",
  "preAuthRef" : "PLJ9147",
  "preAuthPeriod" : {
    "start" : "2021-10-10",
    "end" : "2021-10-12"
  },
  "payeeType" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
        "code" : "provider"
      }
    ]
  },
  "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"
              }
            ]
          }
        }
      ],
      "itemSequence" : 1,
      "noteNumber" : [
        1
      ],
      "adjudication" : [
        {
          "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" : "benefit"
              }
            ]
          },
          "amount" : {
            "value" : 0,
            "currency" : "SAR"
          }
        }
      ]
    }
  ],
  "processNote" : [
    {
      "number" : 1,
      "type" : "print",
      "text" : "Referral to Test Provider 2, authorization #GHD517, for Root Canal"
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/1985"
      }
    }
  ]
}