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10 - Claim Professional Request.json
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10 - Claim Professional Request.json
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{
"resourceType": "Bundle",
"id": "9004205a-65cc-4b97-af94-a04cb5e96260",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2021-10-07T09:39:10.32+03:00",
"entry": [
{
"fullUrl": "urn:uuid:54cf5884-662c-4f1d-85a2-a4a923a96260",
"resource": {
"resourceType": "MessageHeader",
"id": "54cf5884-662c-4f1d-85a2-a4a923a96260",
"meta": {
"profile": [
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]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-request"
},
"destination": [
{
"endpoint": "http://nphies.sa/license/payer-license/N-I-00001",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "N-I-00001"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "N-F-00001"
}
},
"source": {
"endpoint": "http://sgh.com.sa"
},
"focus": [
{
"reference": "http://sgh.com.sa/Claim/296260"
}
]
}
},
{
"fullUrl": "http://sgh.com.sa/Claim/296260",
"resource": {
"resourceType": "Claim",
"id": "296260",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/professional-claim|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-authorization-offline-date",
"valueDateTime": "2021-06-30T11:05:48+03:00"
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-episode",
"valueIdentifier": {
"system": "http://sgh.sa.com/episode",
"value": "SGH_EpisodeID_2314596"
}
}
],
"identifier": [
{
"system": "http://sgh.com.sa/claim",
"value": "req_296260"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "http://sgh.com.sa/Patient/123454186"
},
"created": "2022-02-05",
"insurer": {
"reference": "http://sgh.com.sa/Organization/bff3aa1fbd3648619ac082357bf135db"
},
"provider": {
"reference": "http://sgh.com.sa/Organization/b1b3432921324f97af3be9fd0b1a14ae"
},
"priority": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
"code": "normal"
}
]
},
"related": [
{
"claim": {
"type": "Claim",
"identifier": {
"system": "http://sgh.sa.com/claim",
"value": "req_136211"
}
},
"relationship": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/related-claim-relationship",
"code": "prior"
}
]
}
}
],
"payee": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "http://sni.com.sa/Practitioner/7"
},
"role": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
"code": "primary"
}
]
},
"qualification": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/practice-codes",
"code": "10.08"
}
]
}
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-information-category",
"code": "last-menstrual-period"
}
]
},
"timingDate": "2022-01-07"
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10-am",
"code": "N94.6"
}
]
},
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/diagnosis-type",
"code": "principal"
}
]
}
]
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "http://sgh.com.sa/Coverage/1333"
},
"preAuthRef": [
"DEF987"
]
}
],
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"diagnosisSequence": [
1
],
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-package",
"valueBoolean": false
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-tax",
"valueMoney": {
"value": 15.9,
"currency": "SAR"
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-share",
"valueMoney": {
"value": 20,
"currency": "SAR"
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://sgh.com/patientInvoice",
"value": "Invc-20220120/OP-883923"
}
}
],
"productOrService": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/services",
"code": "83600-00-10"
}
]
},
"servicedDate": "2022-02-05",
"quantity": {
"value": 1
},
"unitPrice": {
"value": 106,
"currency": "SAR"
},
"net": {
"value": 121.9,
"currency": "SAR"
}
}
],
"total": {
"value": 121.9,
"currency": "SAR"
}
}
},
{
"fullUrl": "http://sgh.com.sa/Organization/b1b3432921324f97af3be9fd0b1a14ae",
"resource": {
"resourceType": "Organization",
"id": "b1b3432921324f97af3be9fd0b1a14ae",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "N-F-00001"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Saudi General Hospital"
}
},
{
"fullUrl": "http://sgh.com.sa/Patient/123454186",
"resource": {
"resourceType": "Patient",
"id": "123454186",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "0000000001"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "Mariyam Khaled Osman",
"family": "Osman",
"given": [
"Mariyam",
"Abbas"
]
}
],
"telecom": [
{
"system": "phone",
"value": "+966512345691"
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "Female"
}
]
}
}
]
},
"birthDate": "1984-12-25"
}
},
{
"fullUrl": "http://sgh.com.sa/Organization/bff3aa1fbd3648619ac082357bf135db",
"resource": {
"resourceType": "Organization",
"id": "bff3aa1fbd3648619ac082357bf135db",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "N-I-00001"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "Saudi National Insurance"
}
},
{
"fullUrl": "http://sgh.com.sa/Coverage/1333",
"resource": {
"resourceType": "Coverage",
"id": "1333",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "http://sni.com.sa/memberid",
"value": "0000000001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL",
"display": "extended healthcare"
}
]
},
"subscriber": {
"reference": "http://sgh.com.sa/Patient/123454186"
},
"beneficiary": {
"reference": "http://sgh.com.sa/Patient/123454186"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "Self"
}
]
},
"payor": [
{
"reference": "http://sgh.com.sa/Organization/bff3aa1fbd3648619ac082357bf135db"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "group"
}
]
},
"value": "CB135",
"name": "Insurance Group A"
}
],
"network": "Golden C"
}
},
{
"fullUrl": "http://sni.com.sa/Practitioner/7",
"resource": {
"resourceType": "Practitioner",
"id": "7",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/practitioner|1.0.0"
]
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "MD"
}
]
},
"system": "http://nphies.sa/license/practitioner-license",
"value": "N-P-00003"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "Dr. Amar Moustafa",
"family": "Moustafa",
"given": [
"Dr.",
"Amar"
]
}
]
}
}
]
}