Healthcare Financial Services IG Edition 1
0.3.0 - STU-Ballot
Healthcare Financial Services IG Edition 1
0.3.0 - STU-Ballot
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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<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ClaimResponse 964567</b></p><a name="964567"> </a><a name="hc964567"> </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-advanced-authorization.html">Nphies Advanced Authorizationversion: 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>Advanced Auth Reason</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/advancedAuth-reason medication-dispense}">Medication dispense</span></p><p><b>Newborn</b>: false</p><p><b>Service Provider Extension</b>: <a href="Organization-b1b3432921324f97af3be9fd0b1a14ae.html">Organization Saudi General Hospital</a></p><blockquote><p><b>Diagnosis Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-sequence: 1</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-diagnosisCodeableConcept: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-am I70.0}">Atherosclerosis of aorta</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-type: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/diagnosis-type principal}">Principal Diagnosis</span></li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 1</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category vital-sign-systolic}">Systolic</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 120 mm[Hg]<span style="background: LightGoldenRodYellow"> (Details: UCUM codemm[Hg] = 'mm[Hg]')</span></li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 2</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category vital-sign-diastolic}">Diastolic</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 80 mm[Hg]<span style="background: LightGoldenRodYellow"> (Details: UCUM codemm[Hg] = 'mm[Hg]')</span></li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 3</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category vital-sign-height}">Height</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 133 cm<span style="background: LightGoldenRodYellow"> (Details: UCUM codecm = 'cm')</span></li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 4</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category 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9</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category respiratory-rate}">Respiratory Rate</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 18 /min<span style="background: LightGoldenRodYellow"> (Details: UCUM code/min = '/min')</span></li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 10</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category admission-weight}">Admission Weight</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity: 100 kg<span style="background: LightGoldenRodYellow"> (Details: UCUM codekg = 'kg')</span></li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 11</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category patient-history}">patient history</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: No systemic disease</li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 12</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category investigation-result}">Investigation Result</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-code: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/investigation-result INP}">Investigation(s) not performed</span></li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 13</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category treatment-plan}">Treatment Plan</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: Surgery</li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 14</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category physical-examination}">Physical Examination</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: Stable</li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 15</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category history-of-present-illness}">history Of Present Illness</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString: No history</li></ul></blockquote><blockquote><p><b>Supporting Info Extension</b></p><ul><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence: 16</li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/claim-information-category onset}">Onset</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-code: <span title="Codes:{http://hl7.org/fhir/sid/icd-10-am R07.1}">Chest pain on breathing</span></li><li>http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-timingDate: 2023-12-05</li></ul></blockquote><p><b>identifier</b>: <code>http://sni.com.sa/identifiers/advanced-priorauth</code>/877b345a-c866-4cdd-9a99-d95da2969998</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-123454186.html">Ahmad Khaled Abbas(official) Male, DoB: 1984-12-25 ( Passport Number: G12345678)</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>outcome</b>: Processing Complete</p><p><b>preAuthRef</b>: 23c6dc35-3b13-4837-be6a-fa68ed782a42</p><p><b>preAuthPeriod</b>: 2023-12-05 09:20:15+0300 --> 2023-12-05 09:20:15+0300</p><blockquote><p><b>addItem</b></p><p><b>Maternity</b>: false</p><p><b>Adjudication Outcome</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/adjudication-outcome approved}">Approved</span></p><p><b>Sequence Extension</b>: 1</p><p><b>Diagnosis Sequence Extension</b>: 1</p><p><b>Information Sequence Extension</b>: 1</p><p><b>productOrService</b>: <span title="Codes:{http://nphies.sa/terminology/CodeSystem/procedures 33509-00-00}">Aorta endarterectomy</span></p><p><b>quantity</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://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><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>5000</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>5000</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>750</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-1333.html">Coverage: identifier = http://sni.com.sa/identifiers/memberid#0000000001; status = active; type = extended healthcare; dependent = 01; relationship = Self; network = Golden C</a></td></tr></table></div>
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<code value="approved"/>
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<extension
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<valueCodeableConcept>
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<system
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<extension
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<valueBoolean value="false"/>
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<extension
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<valueReference>🔗
<reference value="Organization/b1b3432921324f97af3be9fd0b1a14ae"/>
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<extension
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<extension
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<valuePositiveInt value="1"/>
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<extension
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<valueCodeableConcept>
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<code value="I70.0"/>
<display value="Atherosclerosis of aorta"/>
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<valueCodeableConcept>
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<system
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<code value="vital-sign-systolic"/>
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<extension
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<valueCodeableConcept>
<coding>
<system
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<code value="vital-sign-height"/>
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<extension
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<valueQuantity>
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<code value="cm"/>
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<extension
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<valueCodeableConcept>
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<extension
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<valuePositiveInt value="5"/>
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<extension
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<valueCodeableConcept>
<coding>
<system
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<code value="pulse"/>
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<extension
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<valueQuantity>
<value value="100"/>
<system value="http://unitsofmeasure.org"/>
<code value="/min"/>
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<extension
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<extension
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</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="temperature"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity">
<valueQuantity>
<value value="70"/>
<system value="http://unitsofmeasure.org"/>
<code value="Cel"/>
</valueQuantity>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-timingPeriod">
<valuePeriod>
<start value="2023-12-05T09:20:15.23+03:00"/>
<end value="2023-12-05T09:20:15.23+03:00"/>
</valuePeriod>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="7"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="chief-complaint"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-code">
<valueCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="81817003"/>
<display value="Atherosclerosis of aorta"/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="8"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="oxygen-saturation"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity">
<valueQuantity>
<value value="100"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</valueQuantity>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="9"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="respiratory-rate"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity">
<valueQuantity>
<value value="18"/>
<system value="http://unitsofmeasure.org"/>
<code value="/min"/>
</valueQuantity>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="10"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="admission-weight"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueQuantity">
<valueQuantity>
<value value="100"/>
<system value="http://unitsofmeasure.org"/>
<code value="kg"/>
</valueQuantity>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="11"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="patient-history"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString">
<valueString value="No systemic disease"/>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="12"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="investigation-result"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-code">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/investigation-result"/>
<code value="INP"/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="13"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="treatment-plan"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString">
<valueString value="Surgery"/>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="14"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="physical-examination"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString">
<valueString value="Stable"/>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="15"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="history-of-present-illness"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-valueString">
<valueString value="No history"/>
</extension>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo">
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-sequence">
<valuePositiveInt value="16"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-category">
<valueCodeableConcept>
<coding>
<system
value="http://nphies.sa/terminology/CodeSystem/claim-information-category"/>
<code value="onset"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-code">
<valueCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-am"/>
<code value="R07.1"/>
</coding>
<text value="Chest pain on breathing"/>
</valueCodeableConcept>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-supportingInfo-timingDate">
<valueDate value="2023-12-05"/>
</extension>
</extension>
<identifier>
<system value="http://sni.com.sa/identifiers/advanced-priorauth"/>
<value value="877b345a-c866-4cdd-9a99-d95da2969998"/>
</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/123454186"/>
</patient>
<created value="2023-12-05"/>
<insurer>🔗
<reference value="Organization/bff3aa1fbd3648619ac082357bf135db"/>
</insurer>
<outcome value="complete"/>
<preAuthRef value="23c6dc35-3b13-4837-be6a-fa68ed782a42"/>
<preAuthPeriod>
<start value="2023-12-05T09:20:15.23+03:00"/>
<end value="2023-12-05T09:20:15.23+03:00"/>
</preAuthPeriod>
<addItem>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-maternity">
<valueBoolean value="false"/>
</extension>
<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-sequence">
<valuePositiveInt value="1"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-diagnosis-sequence">
<valuePositiveInt value="1"/>
</extension>
<extension
url="http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-informationSequence">
<valuePositiveInt value="1"/>
</extension>
<productOrService>
<coding>
<system value="http://nphies.sa/terminology/CodeSystem/procedures"/>
<code value="33509-00-00"/>
<display value="Aorta endarterectomy"/>
</coding>
</productOrService>
<quantity>
<value value="1"/>
</quantity>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="5000"/>
<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="5000"/>
<currency value="SAR"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="tax"/>
</coding>
</category>
<amount>
<value value="750"/>
<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>
</addItem>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="5000"/>
<currency value="SAR"/>
</amount>
</total>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="5000"/>
<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>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="tax"/>
</coding>
</category>
<amount>
<value value="750"/>
<currency value="SAR"/>
</amount>
</total>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/1333"/>
</coverage>
</insurance>
</ClaimResponse>