Kenya eClaims FHIR Implementation Guide
0.1.0 - ci-build KE

Kenya eClaims FHIR Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

: Example Claim Response - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "CR-00001",
  "meta" : {
    "profile" : [
      🔗 "https://fhir.dha.go.ke/eclaims/StructureDefinition/ke-eclaims-claim"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim CR-00001</b></p><a name=\"CR-00001\"> </a><a name=\"hcCR-00001\"> </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-ke-eclaims-claim.html\">Claim Response - Preauthorization</a></p></div><p><b>identifier</b>: <code>https://fhir.dha.go.ke/eclaims/Identifier/claim-number</code>/CLAIM-00001</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:{https://fhir.dha.go.ke/eclaims/CodeSystem/claim-subtype-cs inpatient}\">Inpatient</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href=\"Patient-PT-0001.html\">John Doe  Male, DoB: 1980-01-01</a></p><p><b>billablePeriod</b>: 2025-11-01 --&gt; 2025-11-30</p><p><b>created</b>: 2025-12-16 12:00:00+0300</p><p><b>insurer</b>: <a href=\"Organization-INS-001.html\">Organization Kenya Insurance Company</a></p><p><b>provider</b>: <a href=\"Organization-ORG-001.html\">Organization Nairobi General Hospital</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><h3>Relateds</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Claim</b></td><td><b>Relationship</b></td></tr><tr><td style=\"display: none\">*</td><td><a href=\"Claim-CLAIM-0000X.html\">Claim: status = active; type = Institutional; use = claim; created = 2025-01-01; priority = Normal</a></td><td><span title=\"Codes:{https://fhir.dha.go.ke/eclaims/CodeSystem/related-claim-relationship-cs associated}\">Associated</span></td></tr></table><p><b>originalPrescription</b>: <a href=\"MedicationRequest-MED-0001.html\">MedicationRequest: status = active; intent = order; medication[x] = </a></p><h3>Payees</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}\">Provider</span></td><td><a href=\"Organization-ORG-001.html\">Organization Nairobi General Hospital</a></td></tr></table><p><b>referral</b>: <a href=\"ServiceRequest-SRV-0001.html\">ServiceRequest </a></p><p><b>facility</b>: <a href=\"Location-LOC-001.html\">Location Main Ward</a></p><h3>CareTeams</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td><td><b>Qualification</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><a href=\"Practitioner-PRA-001.html\">Practitioner Dr. James Kamau </a></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claimcareteamrole primary}\">Primary Provider</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0360 MD}\">Doctor of Medicine</span></td></tr></table><h3>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claiminformationcategory attachment}\">Attachment</span></td><td>application/pdf @ https://api-edi.provider.sha.go.ke/media/claim/CHURCHILL_X-RAY.pdf</td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://id.who.int/icd/release/11/mms NC72.5}\">Fracture of shaft of femur</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">Principal Diagnosis</span></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-COV-0001.html\">Coverage: status = active</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{https://fhir.dha.go.ke/eclaims/CodeSystem/KenyaSocialHealthAuthorityInterventionCS SHA-19-444}\">Open reduction and internal fixation: Femur</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</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>145600</td><td>Kenyan shilling</td></tr></table><h3>Nets</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>145600</td><td>Kenyan shilling</td></tr></table></blockquote><h3>Totals</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>145600</td><td>Kenyan shilling</td></tr></table></div>"
  },
  "identifier" : [
    {
      "system" : "https://fhir.dha.go.ke/eclaims/Identifier/claim-number",
      "value" : "CLAIM-00001"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional",
        "display" : "Institutional"
      }
    ]
  },
  "subType" : {
    "coding" : [
      {
        "system" : "https://fhir.dha.go.ke/eclaims/CodeSystem/claim-subtype-cs",
        "code" : "inpatient",
        "display" : "Inpatient"
      }
    ]
  },
  "use" : "preauthorization",
  "patient" : {
    🔗 "reference" : "Patient/PT-0001"
  },
  "billablePeriod" : {
    "start" : "2025-11-01",
    "end" : "2025-11-30"
  },
  "created" : "2025-12-16T12:00:00+03:00",
  "insurer" : {
    🔗 "reference" : "Organization/INS-001"
  },
  "provider" : {
    🔗 "reference" : "Organization/ORG-001"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal",
        "display" : "Normal"
      }
    ]
  },
  "related" : [
    {
      "claim" : {
        🔗 "reference" : "Claim/CLAIM-0000X"
      },
      "relationship" : {
        "coding" : [
          {
            "system" : "https://fhir.dha.go.ke/eclaims/CodeSystem/related-claim-relationship-cs",
            "code" : "associated",
            "display" : "Associated"
          }
        ]
      }
    }
  ],
  "originalPrescription" : {
    🔗 "reference" : "MedicationRequest/MED-0001"
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "provider",
          "display" : "Provider"
        }
      ]
    },
    "party" : {
      🔗 "reference" : "Organization/ORG-001"
    }
  },
  "referral" : {
    🔗 "reference" : "ServiceRequest/SRV-0001"
  },
  "facility" : {
    🔗 "reference" : "Location/LOC-001"
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        🔗 "reference" : "Practitioner/PRA-001"
      },
      "role" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
            "code" : "primary",
            "display" : "Primary Provider"
          }
        ]
      },
      "qualification" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0360",
            "code" : "MD",
            "display" : "Doctor of Medicine"
          }
        ]
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "attachment",
            "display" : "Attachment"
          }
        ]
      },
      "valueAttachment" : {
        "contentType" : "application/pdf",
        "url" : "https://api-edi.provider.sha.go.ke/media/claim/CHURCHILL_X-RAY.pdf",
        "title" : "CHURCHILL X-RAY",
        "creation" : "2025-11-29T15:17:07+03:00"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://id.who.int/icd/release/11/mms",
            "code" : "NC72.5",
            "display" : "Fracture of shaft of femur"
          }
        ]
      },
      "type" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "code" : "principal",
              "display" : "Principal Diagnosis"
            }
          ]
        }
      ]
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/COV-0001"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        1
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "https://fhir.dha.go.ke/eclaims/CodeSystem/KenyaSocialHealthAuthorityInterventionCS",
            "code" : "SHA-19-444",
            "display" : "Open reduction and internal fixation: Femur"
          }
        ]
      },
      "quantity" : {
        "value" : 1
      },
      "unitPrice" : {
        "value" : 145600,
        "currency" : "KES"
      },
      "net" : {
        "value" : 145600,
        "currency" : "KES"
      }
    }
  ],
  "total" : {
    "value" : 145600,
    "currency" : "KES"
  }
}