Healthcare Financial Services IG Edition 1
0.3.0 - STU-Ballot Saudi Arabia flag

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

: Authorization Oral Response #1 - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="618042"/>
  <meta>
    <profile
             value="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|0.3.0"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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>
  </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-transferAuthorizationNumber">
    <valueString value="GHD517"/>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-transferAuthorizationPeriod">
    <valuePeriod>
      <start value="2021-10-10"/>
      <end value="2021-10-12"/>
    </valuePeriod>
  </extension>
  <extension
             url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-transferAuthorizationProvider">
    <valueReference>🔗 
      <reference value="Organization/bff3aa1fbd3648619ac082357bf135ab"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="http://sni.com.sa/identifiers/claimresponse"/>
    <value value="resp_618044"/>
  </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="preauthorization"/>
  <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/authorization"/>
      <value value="req_293093"/>
    </identifier>
  </request>
  <outcome value="complete"/>
  <preAuthRef value="PLJ9147"/>
  <preAuthPeriod>
    <start value="2021-10-10"/>
    <end value="2021-10-12"/>
  </preAuthPeriod>
  <payeeType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
      <code value="provider"/>
    </coding>
  </payeeType>
  <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"/>
    <noteNumber value="1"/>
    <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="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <currency value="SAR"/>
      </amount>
    </adjudication>
  </item>
  <processNote>
    <number value="1"/>
    <type value="print"/>
    <text
          value="Referral to Test Provider 2, authorization #GHD517, for Root Canal"/>
  </processNote>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/1985"/>
    </coverage>
  </insurance>
</ClaimResponse>