Adjudication Outcome: Approved

Advanced Auth Reason: Medication dispense

Newborn: false

Service Provider Extension: Organization Saudi General Hospital

Diagnosis Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-sequence: 1
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-diagnosisCodeableConcept: Atherosclerosis of aorta
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-type: Principal Diagnosis

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 1
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Systolic
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 120 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 2
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Diastolic
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 80 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 3
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Height
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 133 cm (Details: UCUM codecm = 'cm')

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 4
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Weight
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-reason: Not Collected

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 5
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Pulse
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 100 /min (Details: UCUM code/min = '/min')

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 6
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Temperature
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 70 Cel (Details: UCUM codeCel = 'Cel')
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-timingPeriod: 2023-12-05 09:20:15+0300 --> 2023-12-05 09:20:15+0300

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 7
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: chief complaint
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-code: Atherosclerosis of aorta

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 8
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Oxygen Saturation
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 100 % (Details: UCUM code% = '%')

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 9
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Respiratory Rate
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 18 /min (Details: UCUM code/min = '/min')

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 10
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Admission Weight
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 100 kg (Details: UCUM codekg = 'kg')

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 11
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: patient history
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: No systemic disease

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 12
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Investigation Result
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-code: Investigation(s) not performed

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 13
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Treatment Plan
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: Surgery

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 14
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Physical Examination
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: Stable

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 15
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: history Of Present Illness
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: No history

Supporting Info Extension

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 16
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: Onset
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-code: Chest pain on breathing
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-timingDate: 2023-12-05

identifier: http://sni.com.sa/identifiers/advanced-priorauth/877b345a-c866-4cdd-9a99-d95da2969998

status: Active

type: Institutional

subType: InPatient

use: Preauthorization

patient: Ahmad Khaled Abbas(official) Male, DoB: 1984-12-25 ( Passport Number: G12345678)

created: 2023-12-05

insurer: Organization Saudi National Insurance

outcome: Processing Complete

preAuthRef: 23c6dc35-3b13-4837-be6a-fa68ed782a42

preAuthPeriod: 2023-12-05 09:20:15+0300 --> 2023-12-05 09:20:15+0300

addItem

Maternity: false

Adjudication Outcome: Approved

Sequence Extension: 1

Diagnosis Sequence Extension: 1

Information Sequence Extension: 1

productOrService: Aorta endarterectomy

quantity: 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: Tax

Amounts

-	Value	Currency
*	750	Saudi riyal

adjudication

category: Approved Quantity

value: 1

total

category: Eligible Amount

Amounts

-	Value	Currency
*	5000	Saudi riyal

total

category: Benefit Amount

Amounts

-	Value	Currency
*	5000	Saudi riyal

total

category: CoPay

Amounts

-	Value	Currency
*	0	Saudi riyal

total

category: Tax

Amounts

-	Value	Currency
*	750	Saudi riyal

Insurances