Kenya eClaims FHIR Implementation Guide
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Terminology Guidance

Terminology Guidance

This page describes the terminology strategy used in the Kenya eClaims FHIR Implementation Guide — which code systems are used, where they come from, and how they are bound to profile elements.

1. Binding Strength Policy

All coded data elements in this IG use required binding strength. This means:

  • Senders SHALL use a code from the bound ValueSet.
  • Receivers SHALL reject (or flag as invalid) any code that is not in the bound ValueSet.
  • There is no extensibility — implementers may not use codes outside the bound ValueSet without requesting a change to this IG.

This strict approach is deliberately chosen to ensure:

  1. Machine-processability — SHA's adjudication engine can reliably interpret all coded values without case-by-case negotiation.
  2. Fraud prevention — Ambiguous or freely-coded services cannot be claimed against undefined benefit categories.
  3. Interoperability — Multiple EMR vendors producing the same codes enables national-level aggregation without ETL transformation.

2. Code System Sources

This IG draws terminology from three sources, in priority order:

2.1 MOH-Kenya Open Concept Lab (OCL)

The primary source for Kenya-specific clinical and administrative terminology. OCL is operated by the Digital Health Agency of Kenya at:

https://ilm-hie.dha.go.ke/ocl/orgs/MOH-KENYA/

OCL-sourced code systems used in this IG include:

Code System OCL URL Used In
IDENTIFIER-USE .../CodeSystem/IDENTIFIER-USE Patient, Practitioner identifiers
IDENTIFIER-TYPES .../CodeSystem/IDENTIFIER-TYPES Kenya-specific ID document types
NAME-USE .../CodeSystem/NAME-USE Patient and Practitioner name use
CONTACT-POINT-SYSTEM .../CodeSystem/CONTACT-POINT-SYSTEM Telecom contact system
CONTACT-POINT-USE .../CodeSystem/CONTACT-POINT-USE Telecom contact use
ADDRESS-USE .../CodeSystem/ADDRESS-USE Patient/Org address use
ADMINISTRATIVE-GENDER .../CodeSystem/ADMINISTRATIVE-GENDER Practitioner gender
GENDER .../CodeSystem/GENDER Patient gender (extended)
CIVIL-STATUS .../CodeSystem/CIVIL-STATUS Patient marital status
COVERAGE-TYPE .../CodeSystem/COVERAGE-TYPE Insurance coverage type
COVERAGE-CLASS .../CodeSystem/COVERAGE-CLASS Coverage class category
COVERAGE-MEMBER-STATUS .../CodeSystem/COVERAGE-MEMBER-STATUS Member enrollment status
COVERAGE-PLAN-TYPE .../CodeSystem/COVERAGE-PLAN-TYPE Insurance plan type
PAYMENT-METHOD .../CodeSystem/PAYMENT-METHOD Beneficiary payment method
RELATED-CLAIM-RELATIONSHIP .../CodeSystem/RELATED-CLAIM-RELATIONSHIP Relationship between related claims
CLAIM-STATUS .../CodeSystem/CLAIM-STATUS Claim workflow status
CLAIM-TYPE .../CodeSystem/CLAIM-TYPE Institutional vs Professional
CLAIM-SUBTYPE .../CodeSystem/CLAIM-SUBTYPE Claim subtype (Day Case, Rehab, etc.)
CLAIM-USE .../CodeSystem/CLAIM-USE Claim vs Preauthorization
CLAIM-CARE-TEAM-ROLE .../CodeSystem/CLAIM-CARE-TEAM-ROLE Care team member role
CONDITION-CLINICAL-STATUS .../CodeSystem/CONDITION-CLINICAL-STATUS Clinical status of diagnosis
CONDITION-VERIFICATION-STATUS .../CodeSystem/CONDITION-VERIFICATION-STATUS Verification status of diagnosis
CONDITION-CATEGORY .../CodeSystem/CONDITION-CATEGORY Diagnosis category
ENCOUNTER-STATUS .../CodeSystem/ENCOUNTER-STATUS Encounter workflow status
EPISODE-OF-CARE-STATUS .../CodeSystem/EPISODE-OF-CARE-STATUS Episode status
EPISODE-OF-CARE-TYPE .../CodeSystem/EPISODE-OF-CARE-TYPE Kenya health program types
INSTITUTIONAL-BODY-SITE .../CodeSystem/INSTITUTIONAL-BODY-SITE Body sites for claim items
SUBSITE .../CodeSystem/SUBSITE Sub-site laterality
WAIVER-TYPE .../CodeSystem/WAIVER-TYPE Types of coverage waivers
PREAUTH-EXCLUSION-REASON .../CodeSystem/PREAUTH-EXCLUSION-REASON Reasons for preauth exclusion
COVERAGE-EXCLUSION-REASON .../CodeSystem/COVERAGE-EXCLUSION-REASON Reasons for coverage exclusion
KenyaSocialHealthAuthorityInterventions SHA Interventions Catalogue Claim line item service codes
GenericProducts PPB Generic Products Medication codes (pharmacy claims)

2.2 HL7 Terminology (THO)

For coded elements where no MOH-Kenya equivalent exists, this IG uses code systems published by HL7 and its terminology authority (terminology.hl7.org). These include:

Code System Used In Notes
http://hl7.org/fhir/ValueSet/fm-status Coverage.status, PaymentNotice.status FHIR financial module status
http://hl7.org/fhir/ValueSet/claim-type Claim.type (extensible fallback) Standard HL7 claim types
http://hl7.org/fhir/ValueSet/process-priority Claim.priority Standard processing priority
http://hl7.org/fhir/ValueSet/payeetype Claim.payee.type Payee type codes
http://hl7.org/fhir/ValueSet/ex-diagnosistype Claim.diagnosis.type Diagnosis type (principal, secondary, etc.)
http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission Claim.diagnosis.onAdmission Admission status of diagnosis
http://hl7.org/fhir/ValueSet/ex-benefitcategory Claim.item.category Benefit category
http://hl7.org/fhir/ValueSet/fundsreserve Claim.fundsReserve Funds reservation
http://hl7.org/fhir/ValueSet/provider-qualification Claim.careTeam.qualification Practitioner qualifications
http://hl7.org/fhir/ValueSet/claim-informationcategory Claim.supportingInfo.category Supporting information types
http://hl7.org/fhir/ValueSet/subscriber-relationship Coverage.relationship Subscriber-beneficiary relationship
http://hl7.org/fhir/ValueSet/coverage-copay-type Coverage.costToBeneficiary.type Copay category
http://hl7.org/fhir/ValueSet/coverage-financial-exception Coverage.costToBeneficiary.exception.type Financial exception types
http://hl7.org/fhir/ValueSet/service-category Coverage annual limit category Service category for limit tracking
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode Encounter.class Inpatient, Outpatient, Emergency, etc.
http://terminology.hl7.org/ValueSet/v3-ActPriority Encounter.priority Encounter triage priority
http://hl7.org/fhir/ValueSet/diagnosis-role EpisodeOfCare.diagnosis.role Principal, comorbidity, etc.
http://hl7.org/fhir/ValueSet/diagnostic-report-status DiagnosticReport.status Report status
http://hl7.org/fhir/ValueSet/report-codes DiagnosticReport.code LOINC-based report type codes
http://hl7.org/fhir/ValueSet/medicationrequest-status MedicationRequest.status Prescription status
http://hl7.org/fhir/ValueSet/medicationrequest-intent MedicationRequest.intent Prescription intent
http://hl7.org/fhir/ValueSet/medicationrequest-category MedicationRequest.category Prescription setting
http://hl7.org/fhir/ValueSet/request-priority MedicationRequest.priority Urgency
http://terminology.hl7.org/ValueSet/v3-ActPharmacySupplyType MedicationDispense.type Dispense type
http://hl7.org/fhir/ValueSet/medicationdispense-status MedicationDispense.status Dispense status
http://hl7.org/fhir/ValueSet/medication-statement-status MedicationStatement.status Medication statement status
http://hl7.org/fhir/ValueSet/dose-rate-type Dosage.doseAndRate.type Dose rate calculation type
http://terminology.hl7.org/ValueSet/v3-SubstanceAdminSubstitutionReason MedicationRequest.substitution.reason Generic substitution reason
http://hl7.org/fhir/ValueSet/payment-status PaymentNotice.paymentStatus Payment clearance status
http://hl7.org/fhir/ValueSet/adjudication ClaimResponse adjudication Adjudication category
http://hl7.org/fhir/ValueSet/adjudication-reason ClaimResponse adjudication reason Reason for adjudication decision
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode Claim.accident.type Accident/incident codes
http://terminology.hl7.org/ValueSet/v2-2.7-0360 Practitioner.qualification.code HL7 v2 degree/license codes
http://hl7.org/fhir/ValueSet/patient-contactrelationship Patient.contact.relationship Next-of-kin relationship
http://hl7.org/fhir/ValueSet/currencies Claim monetary amounts ISO 4217 currency codes

2.3 Local Kenya Code Systems (No External Source)

For coded elements where SNOMED CT was previously used in FHIR base specifications but is not appropriate for Kenya's licensing and operational context, this IG defines local code systems:

Code System Replaces Used In
ConditionSeverityCS http://hl7.org/fhir/ValueSet/condition-severity (SNOMED CT) Condition.severity
MedicationStatusReasonCS http://hl7.org/fhir/ValueSet/reason-medication-status-codes (SNOMED CT) MedicationStatement.statusReason
DosageAdditionalInstructionCS http://hl7.org/fhir/ValueSet/additional-instruction-codes (SNOMED CT) Dosage.additionalInstruction
AdministrationMethodCS http://hl7.org/fhir/ValueSet/administration-method-codes (SNOMED CT) Dosage.method
AsNeededReasonCS http://hl7.org/fhir/ValueSet/medication-as-needed-reason (SNOMED CT) Dosage.asNeeded[x]

3. SNOMED CT Policy

SNOMED CT is not used in this Implementation Guide.

This decision was made for the following reasons:

  1. Licensing: Kenya does not currently hold a national SNOMED CT license through SNOMED International. Use of SNOMED CT concepts in a required binding would make this IG non-implementable for most Kenya health systems.
  2. Operational Preference: MOH-Kenya and SHA have expressed a preference for terminology maintained and controlled within Kenya's national OCL instance.
  3. Simplicity: For the clinical concepts required in the eClaims context (body sites, medication routes, diagnosis severity), simpler local code systems are sufficient and easier to maintain.

Any FHIR element that references a SNOMED CT-based HL7 ValueSet in the base specification has been replaced with either a MOH-Kenya OCL ValueSet or a locally defined code system.

4. ICD-11 for Diagnosis Coding

Diagnoses in Claim.diagnosis.diagnosisCodeableConcept are drawn from the WHO ICD-11 for Mortality and Morbidity Statistics (MMS). The code system is maintained locally in ClaimDiagnosisCodeableConceptCS and reflects the ICD-11 chapters relevant to the Kenya claims context.

ICD-11 vs ICD-10:

  • This IG uses ICD-11 as the primary coding system, in alignment with Kenya's stated transition to ICD-11 per WHO guidance.
  • ICD-10 codes may be accepted during the transition period via the Claim.diagnosis.diagnosisCodeableConcept element by using the ICD-10 code system URI (http://hl7.org/fhir/sid/icd-10), but ICD-11 is required for all new submissions from facilities that have upgraded.

5. SHA Interventions Catalogue

Claim.item.productOrService SHALL reference a code from the KenyaSocialHealthAuthorityInterventionsVS, which maps to the SHA-approved interventions catalogue. This catalogue is maintained by SHA and synchronized into the MOH-Kenya OCL.

Codes follow the pattern:

  • SHA-01-xxx — Primary Healthcare interventions
  • SHA-02-xxx — Secondary/Tertiary care interventions
  • PMF-xxx — Specialized programme (POMF) interventions

Facilities must ensure their EMR item catalogue is mapped to these SHA codes before submitting claims. SHA will reject any claim line item with a code not in the approved catalogue.

6. Currency

All monetary amounts (Claim.item.unitPrice, Claim.item.net, ClaimResponse.total) use KES (Kenyan Shilling) as the currency code, drawn from the ISO 4217 currencies ValueSet. USD or other foreign currencies are not accepted.

7. Requesting Terminology Changes

To request additions to or corrections of any MOH-Kenya OCL code system used in this IG:

  1. Submit a request via the OCL portal at https://ilm-hie.dha.go.ke/ocl
  2. Include the concept definition, rationale, and example use case
  3. Copy terminology@dha.go.ke on the submission

For changes to locally defined code systems (ConditionSeverityCS, etc.), raise a GitHub issue at the IG repository or contact interoperability@dha.go.ke.