Kenya eClaims FHIR Implementation Guide
0.1.0 - ci-build
KE
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
Contents:
This page provides a list of the FHIR artifacts defined as part of this implementation guide.
These define constraints on FHIR resources for systems conforming to this implementation guide.
| Claim Response - Preauthorization |
This profile defines constraints on the Claim resource for use within the Kenya eClaims Implementation Guide. It supports institutional claims with detailed clinical, financial, insurance, and adjudication metadata. |
| Claim Submission |
This is the final request for payment sent after services are delivered. |
| Coverage Profile |
This profile defines constraints on the Coverage resource for use within the Kenya eClaims Implementation Guide. It represents insurance coverage for a patient under a specific insurance scheme, including SHA and specialised schemes such as POMF and POMF_TEACHERS. |
| Imaging Preauthorization |
This profile is for authorizing high-cost Diagnostic Imaging. |
| Kenya eClaims Base Profile |
This is the foundation for all Financial Claims and Preauthorizations in Kenya. It enforces standard identifiers, actor references (Patient, Provider) and common extensions used across the entire eClaims ecosystem. |
| Kenya eClaims ClaimResponse Profile |
Profile for the response to a Claim or Preauthorization, including specific adjudication states and expiry logic. |
| Oncology Preauthorization |
This profile is for authorizing Cancer Treatment. |
| Optical Preauthorization |
This profile is for Optical Services. |
| Renal Preauthorization |
This profile is for requesting authorization for renal dialysis sessions. |
| Surgical Preauthorization |
This profile covers invasive procedures requiring a theatre or sterile setting. |
| eClaims Condition/Diagnosis Profile |
This profile defines constraints on the Condition resource for use within the Kenya eClaims Implementation Guide. It represents a clinical diagnosis or problem associated with a patient's healthcare encounter. |
| eClaims Diagnostic Report Profile |
This profile defines constraints on the DiagnosticReport resource for use within the Kenya eClaims Implementation Guide. It represents findings from diagnostic tests (lab, radiology, pathology) associated with a claim. |
| eClaims Encounter Profile |
This profile defines constraints on the Encounter resource for use within the Kenya eClaims Implementation Guide. It captures the healthcare interaction during which services are rendered and claims are generated. |
| eClaims Episode of Care Profile |
This profile defines constraints on the EpisodeOfCare resource for use within the Kenya eClaims Implementation Guide. It groups a set of related encounters and activities for a patient within a specific care program. |
| eClaims Medication Dispense Profile |
This profile defines constraints on the MedicationDispense resource for use within the Kenya eClaims Implementation Guide. It represents the dispensing of a medication to a patient. |
| eClaims Medication Request Profile |
This profile defines constraints on the MedicationRequest resource for use within the Kenya eClaims Implementation Guide. It represents a prescription or order for a medication for a patient. |
| eClaims Medication Statement Profile |
This profile defines constraints on the MedicationStatement resource for use within the Kenya eClaims Implementation Guide. It records information about a medication being taken by a patient. |
| eClaims Organization Profile |
This profile defines constraints on the Organization resource for use within the Kenya eClaims Implementation Guide. It represents healthcare providers, insurers, and other organizations involved in claim processing. |
| eClaims Patient Profile |
This profile defines constraints on the Patient resource for use within the Kenya eClaims Implementation Guide. It represents a patient receiving healthcare services under the national insurance scheme. |
| eClaims Payment Notice Profile |
This profile defines constraints on the PaymentNotice resource for use within the Kenya eClaims Implementation Guide. It provides notice of a payment-related event, such as the issuance or receipt of funds for a healthcare claim, supporting financial reconciliation and tracking. |
| eClaims Practitioner Profile |
This profile defines constraints on the Practitioner resource for use within the Kenya eClaims Implementation Guide. It represents a healthcare professional involved in claim processing or service delivery. |
These define constraints on FHIR data types for systems conforming to this implementation guide.
| Anaesthesia Type |
Type of anaesthesia to be used (e.g. 'General', 'Local'). |
| Annual Limits Category Extension |
The category of service to which the limit applies. |
| Attachment Type |
Classifies the attachment (e.g. Discharge Summary, Final Bill). |
| Carcinoma Staging |
Stage of the carcinoma (e.g. 'STAGE_3'). |
| Chief Complaint |
The patient's primary complaint. |
| Claim Workflow State |
Tracks the specific state of the claim (e.g., Sent Back, Approved, surveillance). |
| Clinical Indications |
Clinical reasoning or specific indications for the procedure (e.g., 'End Stage Renal Disease'). |
| Consultation Amount |
The amount charged for the optical consultation service. |
| Cost Per Session |
The cost per chemotherapy/radiotherapy session. |
| Current member status Extension |
Current member status |
| Exclusion Extension |
A list of services or conditions that are explicitly not covered by this plan. |
| Eye Examination Amount |
The amount charged for the eye examination service. |
| Frame Amount |
The amount charged for spectacle frames. |
| Has Coinsurance |
Indicates if the patient has a coinsurance liability. |
| History of Present Illness |
Detailed history of the present illness. |
| Investigations |
List of investigations performed or requested (e.g. specific lab tests or imaging modalities). |
| Item Coverage Reference |
Link to the specific coverage/scheme applicable to this line item. |
| Last Replacement Date |
Date when the item was last replaced (for eligibility checks). |
| Lens Amount |
The amount charged for spectacle lenses. |
| Lens Prescription |
Details of the lens prescription (Sphere, Cylinder, Axis). |
| Metastases |
Details on metastases (e.g. 'None', 'Bone', 'Liver'). |
| Other Metastases |
Details on additional metastases not captured in the main metastases field. |
| Patient Invoice Details |
Details regarding the provider's invoice and patient liability. |
| Paymen tMethod Extension |
The preferred method of payment for the beneficiary's share (e.g., credit card, direct debit). |
| Physical Examination |
Findings from the physical examination. |
| Plan Type Extension |
The specific type of plan |
| Preauthorization Expiry Date |
Indicates when the approved preauthorization expires. |
| Preauthorization Expiry Date |
Services excluded from preauthorization. |
| Preauthorization Expiry Date |
Indicates when the approved preauthorization expires. |
| Preauthorization Token |
The specific unique token generated for this preauthorization request. |
| Provider Auth Token |
The authorization token issued to the provider for this session. |
| Raw Preauth Source Data |
Container for the full legacy JSON payload. |
| Reason For Service |
The reason for the optical service (e.g., 'Glasses'). |
| Replacement Type |
Indicates if this item is 'New' or a 'Replacement'. |
| Session Expected Date |
The expected date for the dialysis or therapy session. |
| Treatment Setting |
Setting where treatment is provided (e.g. 'DAY_WARD', 'INPATIENT'). |
| Vital Signs |
Recorded vital signs (e.g. Temperature, BP). |
These define sets of codes used by systems conforming to this implementation guide.
| Address Use ValueSet |
ValueSet for address use codes (MOH-Kenya OCL: ADDRESS-USE) |
| Administration Method ValueSet |
ValueSet for medication administration methods (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/administration-method-codes) |
| Administrative Gender ValueSet |
ValueSet for administrative gender codes (MOH-Kenya OCL: ADMINISTRATIVE-GENDER) |
| As Needed Reason ValueSet |
ValueSet for conditions that trigger as-needed medication use (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/medication-as-needed-reason) |
| Attachment Type ValueSet |
ValueSet for types of attachments submitted with a claim in Kenya eClaims. |
| Civil Status ValueSet |
ValueSet for civil/marital status codes (MOH-Kenya OCL: CIVIL-STATUS) |
| Claim Care Team Role ValueSet |
ValueSet for the role of a care team member in a claim (MOH-Kenya OCL: CLAIM-CARE-TEAM-ROLE) |
| Claim Diagnosis ValueSet |
ValueSet for diagnosis codes used in Kenya eClaims, based on ICD-11 categories |
| Claim Status ValueSet |
ValueSet for claim status codes (MOH-Kenya OCL: CLAIM-STATUS) |
| Claim Subtype ValueSet |
ValueSet for claim subtype codes (MOH-Kenya OCL: CLAIM-SUBTYPE) |
| Claim Type ValueSet |
ValueSet for claim type codes (MOH-Kenya OCL: CLAIM-TYPE) |
| Claim Use ValueSet |
ValueSet for intended use of a claim (MOH-Kenya OCL: CLAIM-USE) |
| Condition Category ValueSet |
ValueSet for condition category codes (MOH-Kenya OCL: CONDITION-CATEGORY) |
| Condition Clinical Status ValueSet |
ValueSet for condition clinical status codes (MOH-Kenya OCL: CONDITION-CLINICAL-STATUS) |
| Condition Codes ValueSet |
ValueSet for condition/diagnosis codes (MOH-Kenya: CONDITION-CODES) |
| Condition Severity ValueSet |
ValueSet for the clinical severity of a condition (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/condition-severity) |
| Condition Verification Status ValueSet |
ValueSet for condition verification status codes (MOH-Kenya OCL: CONDITION-VERIFICATION-STATUS) |
| Contact Point System ValueSet |
ValueSet for contact point system codes (MOH-Kenya OCL: CONTACT-POINT-SYSTEM) |
| Contact Point Use ValueSet |
ValueSet for contact point use codes (MOH-Kenya OCL: CONTACT-POINT-USE) |
| Coverage Class ValueSet |
ValueSet for insurance coverage class codes (MOH-Kenya OCL: COVERAGE-CLASS) |
| Coverage Exclusion Reason ValueSet |
ValueSet for reasons a service is excluded from coverage in Kenya health insurance (MOH-Kenya OCL: COVERAGE-EXCLUSION-REASON) |
| Coverage Member Status ValueSet |
ValueSet for the status of a coverage member (MOH-Kenya OCL: COVERAGE-MEMBER-STATUS) |
| Coverage Plan Type ValueSet |
ValueSet for coverage plan type codes (MOH-Kenya OCL: COVERAGE-PLAN-TYPE) |
| Coverage Type ValueSet |
ValueSet for insurance coverage type codes (MOH-Kenya OCL: COVERAGE-TYPE) |
| Dosage Additional Instruction ValueSet |
ValueSet for additional dosage/dispensing instructions (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/additional-instruction-codes) |
| Encounter Status ValueSet |
ValueSet for encounter status codes (MOH-Kenya OCL: ENCOUNTER-STATUS) |
| Episode of Care Status ValueSet |
ValueSet for episode of care status codes (MOH-Kenya OCL: EPISODE-OF-CARE-STATUS) |
| Episode of Care Type ValueSet |
ValueSet for episode of care type codes (MOH-Kenya OCL: EPISODE-OF-CARE-TYPE) |
| Gender ValueSet |
ValueSet for extended gender codes in Kenya (MOH-Kenya OCL: GENDER) |
| Generic Products ValueSet |
ValueSet for generic pharmaceutical products (MOH-Kenya: GenericProducts) |
| Identifier Types ValueSet |
ValueSet for identifier type codes used in Kenya (MOH-Kenya OCL: IDENTIFIER-TYPES) |
| Identifier Use ValueSet |
ValueSet for identifier use codes (MOH-Kenya OCL: IDENTIFIER-USE) |
| Kenya Institutional Body Site ValueSet |
ValueSet for body site codes used in Kenya institutional claims (MOH-Kenya OCL: INSTITUTIONAL-BODY-SITE) |
| Kenya Social Health Authority Interventions ValueSet |
ValueSet for interventions approved by the Kenya Social Health Authority (MOH-Kenya OCL: KenyaSocialHealthAuthorityInterventions) |
| Kenya Subsite ValueSet |
ValueSet for sub-site codes used in Kenya claims (MOH-Kenya OCL: SUBSITE) |
| Medication Status Reason ValueSet |
ValueSet for reasons a medication was stopped or paused (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/reason-medication-status-codes) |
| Name Use ValueSet |
ValueSet for name use codes (MOH-Kenya OCL: NAME-USE) |
| Payment Method ValueSet |
ValueSet for payment method codes (MOH-Kenya OCL: PAYMENT-METHOD) |
| Preauthorization Exclusion Reason ValueSet |
ValueSet for reasons a service may be excluded from preauthorization in Kenya (MOH-Kenya OCL: PREAUTH-EXCLUSION-REASON) |
| Related Claim Relationship ValueSet |
ValueSet for related claim relationship codes (MOH-Kenya OCL: RELATED-CLAIM-RELATIONSHIP) |
| Waiver Type ValueSet |
ValueSet for types of waivers applicable in Kenya health insurance claims (MOH-Kenya OCL: WAIVER-TYPE) |
These define new code systems used by systems conforming to this implementation guide.
| Address Use Code System |
Codes for the use of an address. Codes align with FHIR address-use to allow required binding as a subset. |
| Administration Method Code System |
Codes for the method of medication administration, replacing SNOMED CT-based HL7 ValueSet |
| Administrative Gender Code System |
Codes for administrative gender. Codes align with FHIR administrative-gender to allow required binding as a subset. |
| As Needed Reason Code System |
Codes for the condition that triggers as-needed medication use, replacing SNOMED CT-based HL7 ValueSet |
| Attachment Type Code System |
Codes classifying the type of attachment submitted with a claim (e.g. Discharge Summary, Final Bill). |
| BodySite Code System |
A code system that defines categories for Institutional Body Sites |
| Civil Status Code System |
Codes for civil/marital status (MOH-Kenya OCL: CIVIL-STATUS) |
| Claim Care Team Role Code System |
Codes for the role of a care team member in a claim (MOH-Kenya OCL: CLAIM-CARE-TEAM-ROLE) |
| Claim Expiry Code System |
Codes for claim or preauthorization expiry types in Kenya eClaims. |
| Claim State Code System |
Codes for the specific workflow state of a claim in Kenya eClaims. |
| Claim Status Code System |
Codes for the status of a claim. Codes align with FHIR fm-status to allow required binding as a subset. |
| Claim Subtype Code System |
Kenya-specific codes for the subtype of claim (MOH-Kenya OCL: CLAIM-SUBTYPE). |
| Claim Type Code System |
Codes for the type of claim. Codes align with FHIR claim-type to allow required binding as a subset. |
| Claim Use Code System |
Codes for the intended use of a claim. Codes align with FHIR claim-use to allow required binding as a subset. |
| Condition Category Code System |
A code system that defines categories for Social Health Authority Interventions |
| Condition Category Code System |
Codes for the category of a condition (MOH-Kenya OCL: CONDITION-CATEGORY) |
| Condition Clinical Status Code System |
Codes for the clinical status of a condition. Codes align with FHIR condition-clinical to allow required binding as a subset. |
| Condition Codes Code System |
Local codes for conditions/diagnoses (MOH-Kenya: CONDITION-CODES) |
| Condition Severity Code System |
Codes for the clinical severity of a condition, replacing SNOMED CT-based HL7 ValueSet |
| Condition Verification Status Code System |
Codes for the verification status of a condition. Codes align with FHIR condition-ver-status to allow required binding as a subset. |
| Contact Point System Code System |
Codes for contact point systems. Codes align with FHIR contact-point-system to allow required binding as a subset. |
| Contact Point Use Code System |
Codes for contact point use. Codes align with FHIR contact-point-use to allow required binding as a subset. |
| Coverage Class Code System |
Codes for insurance coverage class categories (MOH-Kenya OCL: COVERAGE-CLASS) |
| Coverage Member Status Code System |
Codes for the status of a coverage member (MOH-Kenya OCL: COVERAGE-MEMBER-STATUS) |
| Coverage Plan Type Code System |
Codes for types of coverage plan (MOH-Kenya OCL: COVERAGE-PLAN-TYPE) |
| Coverage Type Code System |
Codes for the type of insurance coverage (MOH-Kenya OCL: COVERAGE-TYPE) |
| Dosage Additional Instruction Code System |
Codes for additional dispensing/dosage instructions, replacing SNOMED CT-based HL7 ValueSet |
| Encounter Status Code System |
Codes for the status of an encounter. Codes align with FHIR encounter-status to allow required binding as a subset. |
| Episode of Care Status Code System |
Codes for the status of an episode of care. Codes align with FHIR episode-of-care-status to allow required binding as a subset. |
| Episode of Care Type Code System |
Codes for the type of episode of care (MOH-Kenya OCL: EPISODE-OF-CARE-TYPE) |
| Exclusion Code System |
A code system that defines Exclusion |
| Gender Code System |
Extended gender identity codes for Kenya (MOH-Kenya OCL: GENDER). Extends beyond FHIR administrative-gender with additional local codes. |
| Generic Products Code System |
Codes for generic pharmaceutical products used in Kenya dispensing (MOH-Kenya: GenericProducts) |
| Identifier Types Code System |
Codes for types of identifiers used in Kenya (MOH-Kenya OCL: IDENTIFIER-TYPES) |
| Identifier Use Code System |
Codes for the use of an identifier. Codes align with FHIR identifier-use to allow required binding as a subset. |
| Medication Status Reason Code System |
Codes for the reason a medication was stopped or paused, replacing SNOMED CT-based HL7 ValueSet |
| Name Use Code System |
Codes for the use of a name. Codes align with FHIR name-use to allow required binding as a subset. |
| Payment Method Code System |
Codes for payment methods (MOH-Kenya OCL: PAYMENT-METHOD) |
| PreAuthExclusions Code System |
A code system that defines PreAuth Exclusions |
| Related Claim Relationship Code System |
Codes for the relationship between related claims (MOH-Kenya OCL: RELATED-CLAIM-RELATIONSHIP) |
| Subsite Code System |
A code system that defines Subsite |
| Subsite Code System |
A code system that defines Subsite |
| Waiver Type Code System |
A code system that defines Waiver Type |
These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.
| Example Claim Response |
An example Claim Response resource for Kenya eClaims Preauthorization, fully populated for testing. |
| Example Claim for ClaimResponse (canceled) |
Stub claim used as a reference target in the ClaimResponseCanceledExample. |
| Example Claim for ClaimResponse (sent-back) |
Stub claim used as a reference target in the ClaimResponseSentBackExample. |
| Example ClaimResponse - Canceled |
An example of a Preauthorization that was canceled by request. |
| Example ClaimResponse - Sent Back |
An example of a ClaimResponse returned to the provider for surveillance review. |
| Example Coverage |
Stub coverage used as a reference target in claim examples. |
| Example Insurer Organization |
Stub insurer organization used as a reference target in claim examples. |
| Example Location |
Stub location used as a reference target in claim examples. |
| Example Medication Request |
Stub medication request used as a reference target in claim examples. |
| Example Patient |
Stub patient instance used as a reference target in claim examples. |
| Example Patient (generic) |
Stub patient instance used as a reference target in claim response examples. |
| Example Practitioner |
Stub practitioner used as a reference target in claim examples. |
| Example Provider Organization |
Stub provider organization used as a reference target in claim examples. |
| Example Related Claim |
Stub related claim used as a reference target in claim examples. |
| Example Service Request |
Stub service request used as a reference target in claim examples. |
| Social Health Authority |
Stub SHA insurer organization used as a reference target in claim response examples. |