{ "resourceType": "Bundle", "id": "24514acd-e171-4bca-a87a-da2680ec937d", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-28T08:09:02.797+03:00", "entry": [ { "fullUrl": "http://nphies.sa/MessageHeader/f588390f-2c0e-43bd-99ba-80c4c89d18d1", "resource": { "resourceType": "MessageHeader", "id": "f588390f-2c0e-43bd-99ba-80c4c89d18d1", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ], "tag": [ { "system": "http://nphies.sa/terminology/CodeSystem/meta-tags", "code": "queued-messages" } ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "poll-response" }, "destination": [ { "endpoint": "http://nphies.sa/license/provider-license/10000300062591", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/nphies", "value": "NPHIES" } }, "source": { "endpoint": "http://nphies.sa/" }, "response": { "identifier": "87d68960-7616-4fcb-ad14-3e80443ae59a", "code": "ok" } } }, { "fullUrl": "http://nphies.sa/Task/9322df70-c695-4a82-8d6e-a789c13606df", "resource": { "resourceType": "Task", "id": "9322df70-c695-4a82-8d6e-a789c13606df", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/task|1.0.0" ], "tag": [ { "code": "NPHIES generated", "display": "NPHIES generated" } ] }, "identifier": [ { "system": "http://www.ALKholood.com/Task", "value": "111" } ], "status": "completed", "intent": "order", "priority": "stat", "code": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/task-code", "code": "poll" } ] }, "authoredOn": "2026-09-28", "lastModified": "2026-10-28", "requester": { "reference": "Organization/9" }, "owner": { "identifier": { "system": "http://nphies.sa/license/nphies", "value": "NPHIES" } }, "input": [ { "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/task-input-type", "code": "include-message-type" } ] }, "valueCode": "claim-response" }, { "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/task-input-type", "code": "period" } ] }, "valuePeriod": { "start": "2026-09-28T00:00:00.000+03:00", "end": "2026-10-28T23:59:59.999+03:00" } }, { "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/task-input-type", "code": "count" } ] }, "valuePositiveInt": 10 } ], "output": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:07.850+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/98c498f9-47a7-4dd6-a928-9a16575973b0" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:07.851+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/fc7b5b73-7e12-4178-9fec-d966538eb9ed" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:07.853+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/ae0ce970-f12a-43b5-a5b0-718b00a6a267" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:07.981+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/3609986c-8701-4c88-a8cc-faf4f94909e0" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:08.093+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/d5eebac1-581b-4c14-8b8b-a3161b45fa6d" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:08.302+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/29a3ef5a-3361-4d10-ba7d-cf16a4699f3b" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:08.370+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/d312c2ee-a2f5-4b8a-8bf9-2e7c7669132a" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:08.376+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/42c3105a-087f-4e12-8f99-03d94b3bc58b" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:08.474+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/40123d26-eb15-4550-93b0-8da190fc4bc3" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-20T08:52:08.514+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/e3c3897b-e093-4211-89f4-176c4b7916a8" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/98c498f9-47a7-4dd6-a928-9a16575973b0", "resource": { "resourceType": "Bundle", "id": "98c498f9-47a7-4dd6-a928-9a16575973b0", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:07.516+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/c897ce73-1db4-4afe-9702-79ad197e2da8", "resource": { "resourceType": "MessageHeader", "id": "c897ce73-1db4-4afe-9702-79ad197e2da8", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "cf554e67-e1c5-4f95-9a98-6c33b6a483bf", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/57d49f04-4de7-434a-ae48-8f51ce8136fd" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/57d49f04-4de7-434a-ae48-8f51ce8136fd", "resource": { "resourceType": "ClaimResponse", "id": "57d49f04-4de7-434a-ae48-8f51ce8136fd", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "partial" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "228" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "57d49f04-4de7-434a-ae48-8f51ce8136fd" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "oral" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "https://tawuniya.com.sa/Patient/2c91cbe9-6ee1-4973-af8a-af2b26a527a6" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/23e780c4-f2e8-4bd2-93e0-ec4f307d6f05" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/4af3aead-a69c-4c07-822d-2b98ecd272f4" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "60126807260903" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77307" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 140.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 197.12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 21.12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 197.12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 35.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77307" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "MN-1-1" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 3.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 18.48, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 18.48, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 215.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 140.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 38.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 215.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 21.12, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/ecf5286e-feb4-43e2-9d3a-66dfb310503b" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/2c91cbe9-6ee1-4973-af8a-af2b26a527a6", "resource": { "resourceType": "Patient", "id": "2c91cbe9-6ee1-4973-af8a-af2b26a527a6", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1133725463" } ], "active": true, "name": [ { "use": "official", "text": "manar MAATOQ Mohamad alsaeidi", "given": [ "manar", "Mohamad", "alsaeidi" ] } ], "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": "2006-04-10", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/4af3aead-a69c-4c07-822d-2b98ecd272f4", "resource": { "resourceType": "Organization", "id": "4af3aead-a69c-4c07-822d-2b98ecd272f4", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/23e780c4-f2e8-4bd2-93e0-ec4f307d6f05", "resource": { "resourceType": "Organization", "id": "23e780c4-f2e8-4bd2-93e0-ec4f307d6f05", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/ecf5286e-feb4-43e2-9d3a-66dfb310503b", "resource": { "resourceType": "Coverage", "id": "ecf5286e-feb4-43e2-9d3a-66dfb310503b", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "001133725463001" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/e1f2e5e0-aead-4527-932f-e1a48e463e19" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/8344fa8b-da29-4bc3-a136-3d9671c4c1ac" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/2c91cbe9-6ee1-4973-af8a-af2b26a527a6" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/23e780c4-f2e8-4bd2-93e0-ec4f307d6f05" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "55255797", "name": "APPAREL TRADING COMPNAY" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/e1f2e5e0-aead-4527-932f-e1a48e463e19", "resource": { "resourceType": "Organization", "id": "e1f2e5e0-aead-4527-932f-e1a48e463e19", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/8344fa8b-da29-4bc3-a136-3d9671c4c1ac", "resource": { "resourceType": "Patient", "id": "8344fa8b-da29-4bc3-a136-3d9671c4c1ac", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1133725463" } ], "active": true, "name": [ { "use": "official", "text": "manar MAATOQ Mohamad alsaeidi", "given": [ "manar", "Mohamad", "alsaeidi" ] } ], "telecom": [ { "system": "phone", "value": "0565492619" } ], "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": "2006-04-10", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/fc7b5b73-7e12-4178-9fec-d966538eb9ed", "resource": { "resourceType": "Bundle", "id": "fc7b5b73-7e12-4178-9fec-d966538eb9ed", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:07.515+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/91d28c47-9de8-46e4-81f6-7f8459190593", "resource": { "resourceType": "MessageHeader", "id": "91d28c47-9de8-46e4-81f6-7f8459190593", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "d59f8e3a-c5d2-4e1c-93ff-b21b4420233b", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/97d5950f-0c37-41fe-9184-3b6bf984c119" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/97d5950f-0c37-41fe-9184-3b6bf984c119", "resource": { "resourceType": "ClaimResponse", "id": "97d5950f-0c37-41fe-9184-3b6bf984c119", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "partial" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "337" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "97d5950f-0c37-41fe-9184-3b6bf984c119" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "oral" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "https://tawuniya.com.sa/Patient/2e388314-d35a-484a-94de-ec02736d10a2" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/5aaf08b0-aba0-4266-8e0f-418dd80f4fb7" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/9203460d-c33f-41cc-be65-f1b99a63bf99" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "44129676260905" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78648" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "MN-1-1" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 18.48, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 18.48, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 3.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78648" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 5.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 35.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 8.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 49.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 49.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 67.76, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 35.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 12.1, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 67.76, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 5.28, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/42cb9472-a2f8-4fe6-a596-dd2953bed0a1" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/2e388314-d35a-484a-94de-ec02736d10a2", "resource": { "resourceType": "Patient", "id": "2e388314-d35a-484a-94de-ec02736d10a2", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1177739560" } ], "active": true, "name": [ { "use": "official", "text": "AMIR Hasan ABO OF", "given": [ "AMIR", "Hasan", "ABO OF" ] } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "2016-04-15", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/9203460d-c33f-41cc-be65-f1b99a63bf99", "resource": { "resourceType": "Organization", "id": "9203460d-c33f-41cc-be65-f1b99a63bf99", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/5aaf08b0-aba0-4266-8e0f-418dd80f4fb7", "resource": { "resourceType": "Organization", "id": "5aaf08b0-aba0-4266-8e0f-418dd80f4fb7", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/42cb9472-a2f8-4fe6-a596-dd2953bed0a1", "resource": { "resourceType": "Coverage", "id": "42cb9472-a2f8-4fe6-a596-dd2953bed0a1", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "001010553186221" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/bd27a438-c41e-40b6-becc-2e7f5999a7c6" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/83843fe7-85a5-4da5-80c9-3396de025f4f" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/2e388314-d35a-484a-94de-ec02736d10a2" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/5aaf08b0-aba0-4266-8e0f-418dd80f4fb7" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "54657599", "name": "OBAIKAN AGS FOR GLASS" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/bd27a438-c41e-40b6-becc-2e7f5999a7c6", "resource": { "resourceType": "Organization", "id": "bd27a438-c41e-40b6-becc-2e7f5999a7c6", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/83843fe7-85a5-4da5-80c9-3396de025f4f", "resource": { "resourceType": "Patient", "id": "83843fe7-85a5-4da5-80c9-3396de025f4f", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1177739560" } ], "active": true, "name": [ { "use": "official", "text": "AMIR Hasan ABO OF", "given": [ "AMIR", "Hasan", "ABO OF" ] } ], "telecom": [ { "system": "phone", "value": "0544085904" } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "2016-04-15", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/ae0ce970-f12a-43b5-a5b0-718b00a6a267", "resource": { "resourceType": "Bundle", "id": "ae0ce970-f12a-43b5-a5b0-718b00a6a267", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:05.861+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/e53660cc-4f2f-4400-a968-09ccb22289c3", "resource": { "resourceType": "MessageHeader", "id": "e53660cc-4f2f-4400-a968-09ccb22289c3", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "864ffbe7-4c25-4323-8115-607bbda3ea16", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/b7ec6cdc-f8fd-40fb-bce5-a1eb037a4ab0" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/b7ec6cdc-f8fd-40fb-bce5-a1eb037a4ab0", "resource": { "resourceType": "ClaimResponse", "id": "b7ec6cdc-f8fd-40fb-bce5-a1eb037a4ab0", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "182" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "b7ec6cdc-f8fd-40fb-bce5-a1eb037a4ab0" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "oral" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "https://tawuniya.com.sa/Patient/b2b01337-8ee3-4308-938f-999c1e6717e7" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/2a34fbf8-38e3-4ec6-bcc7-aabc1c01c2c8" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/c211fe77-f0dc-4579-93e7-b7262c10b979" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "65125956260903" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "76908" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 140.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 202.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 21.12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 202.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "76908" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 202.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 202.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 140.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 21.12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "76908" } } ], "itemSequence": 3, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 202.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 171.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 25.71, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 202.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 607.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 453, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 607.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 67.95, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/8f0bc9a6-052e-430a-8801-2b5e15718737" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/b2b01337-8ee3-4308-938f-999c1e6717e7", "resource": { "resourceType": "Patient", "id": "b2b01337-8ee3-4308-938f-999c1e6717e7", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1144967427" } ], "active": true, "name": [ { "use": "official", "text": "lauar ahmed ahmed الحازمى", "given": [ "lauar", "ahmed", "الحازمى" ] } ], "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": "2008-05-23", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/c211fe77-f0dc-4579-93e7-b7262c10b979", "resource": { "resourceType": "Organization", "id": "c211fe77-f0dc-4579-93e7-b7262c10b979", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/2a34fbf8-38e3-4ec6-bcc7-aabc1c01c2c8", "resource": { "resourceType": "Organization", "id": "2a34fbf8-38e3-4ec6-bcc7-aabc1c01c2c8", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/8f0bc9a6-052e-430a-8801-2b5e15718737", "resource": { "resourceType": "Coverage", "id": "8f0bc9a6-052e-430a-8801-2b5e15718737", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "001004509202221" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/7ce843cd-af63-4049-8a08-0c074d6b239d" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/427960b8-e8d0-4224-bd93-531242b45e24" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/b2b01337-8ee3-4308-938f-999c1e6717e7" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/2a34fbf8-38e3-4ec6-bcc7-aabc1c01c2c8" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "55530273", "name": "RAWAHEL ALMASHAER CO" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/7ce843cd-af63-4049-8a08-0c074d6b239d", "resource": { "resourceType": "Organization", "id": "7ce843cd-af63-4049-8a08-0c074d6b239d", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/427960b8-e8d0-4224-bd93-531242b45e24", "resource": { "resourceType": "Patient", "id": "427960b8-e8d0-4224-bd93-531242b45e24", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1144967427" } ], "active": true, "name": [ { "use": "official", "text": "lauar ahmed ahmed الحازمى", "given": [ "lauar", "ahmed", "الحازمى" ] } ], "telecom": [ { "system": "phone", "value": "0531833325" } ], "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": "2008-05-23", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/3609986c-8701-4c88-a8cc-faf4f94909e0", "resource": { "resourceType": "Bundle", "id": "3609986c-8701-4c88-a8cc-faf4f94909e0", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:07.613+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/48505ab5-7331-4168-9d8a-4b103a355a6b", "resource": { "resourceType": "MessageHeader", "id": "48505ab5-7331-4168-9d8a-4b103a355a6b", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "54e472a9-f659-49f8-ab59-caa97f9a0c08", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/ac4b00ec-1ce0-4dcb-bf2e-51a82f0fc3cd" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/ac4b00ec-1ce0-4dcb-bf2e-51a82f0fc3cd", "resource": { "resourceType": "ClaimResponse", "id": "ac4b00ec-1ce0-4dcb-bf2e-51a82f0fc3cd", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "268" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "ac4b00ec-1ce0-4dcb-bf2e-51a82f0fc3cd" } ], "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": "https://tawuniya.com.sa/Patient/9286a62f-bc97-4a32-a223-a243b4b9623a" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/8d831f7b-2524-43f0-9df7-56d3faeb387f" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/dc8c418d-bc66-4cb3-b342-ee51d269396f" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "33127684260903" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77668" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 66, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 92.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 9.9, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 92.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 16.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77668" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 120.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 86, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 21.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 120.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 12.9, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/456df3f7-0341-4d04-93e1-56160fa097ad" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/9286a62f-bc97-4a32-a223-a243b4b9623a", "resource": { "resourceType": "Patient", "id": "9286a62f-bc97-4a32-a223-a243b4b9623a", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2099606077" } ], "active": true, "name": [ { "use": "official", "text": "raghda muhammad MSLEH MSLEH", "given": [ "raghda", "MSLEH", "MSLEH" ] } ], "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": "1994-05-04", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/dc8c418d-bc66-4cb3-b342-ee51d269396f", "resource": { "resourceType": "Organization", "id": "dc8c418d-bc66-4cb3-b342-ee51d269396f", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/8d831f7b-2524-43f0-9df7-56d3faeb387f", "resource": { "resourceType": "Organization", "id": "8d831f7b-2524-43f0-9df7-56d3faeb387f", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/456df3f7-0341-4d04-93e1-56160fa097ad", "resource": { "resourceType": "Coverage", "id": "456df3f7-0341-4d04-93e1-56160fa097ad", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "001062450554111" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/3b14a703-24a1-432c-96cf-a37b32c1b768" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/0b908ec9-f1e0-48c5-a2b9-6013ddc33fa7" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/9286a62f-bc97-4a32-a223-a243b4b9623a" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/8d831f7b-2524-43f0-9df7-56d3faeb387f" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "55616574", "name": "CIVIL WORKS COMPANY LTD" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/3b14a703-24a1-432c-96cf-a37b32c1b768", "resource": { "resourceType": "Organization", "id": "3b14a703-24a1-432c-96cf-a37b32c1b768", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/0b908ec9-f1e0-48c5-a2b9-6013ddc33fa7", "resource": { "resourceType": "Patient", "id": "0b908ec9-f1e0-48c5-a2b9-6013ddc33fa7", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2099606077" } ], "active": true, "name": [ { "use": "official", "text": "raghda muhammad MSLEH MSLEH", "given": [ "raghda", "MSLEH", "MSLEH" ] } ], "telecom": [ { "system": "phone", "value": "0590008066" } ], "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": "1994-05-04", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/d5eebac1-581b-4c14-8b8b-a3161b45fa6d", "resource": { "resourceType": "Bundle", "id": "d5eebac1-581b-4c14-8b8b-a3161b45fa6d", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:07.559+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/01718645-e24e-4ee0-a67f-2c46e2302720", "resource": { "resourceType": "MessageHeader", "id": "01718645-e24e-4ee0-a67f-2c46e2302720", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "ba97605c-4f88-4730-8eeb-c5ab483be61b", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/da14fd43-e377-4fc0-8d07-1dd887f2cd8b" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/da14fd43-e377-4fc0-8d07-1dd887f2cd8b", "resource": { "resourceType": "ClaimResponse", "id": "da14fd43-e377-4fc0-8d07-1dd887f2cd8b", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "partial" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "271" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "da14fd43-e377-4fc0-8d07-1dd887f2cd8b" } ], "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": "https://tawuniya.com.sa/Patient/b901366e-9ee4-4498-995f-b8a744725d94" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/c34f255e-d23c-4b03-b8fb-c1f531d6a12e" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/73daa5f0-3a7b-4438-b0ff-aa76646f171a" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "42127719260903" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 25.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 25.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 22, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 31.62, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 31.62, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 4.13, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 27.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 3, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 139.15, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 139.15, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 18.15, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 121, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 4, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 63.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 63.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 8.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 55, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 5, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28.75, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28.75, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0.75, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 6, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 158.12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 158.12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "MN-1-1" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 7, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 25.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 25.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "AD-1-4" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 8, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 63.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 63.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 8.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 55, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 9, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 63.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 63.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 8.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 55, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 10, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 50.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 50.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "AD-1-4" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 11, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 31.62, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 31.62, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 4.13, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 27.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 12, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 25.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 25.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "AD-1-4" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 13, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 31.62, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 31.62, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 4.13, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 27.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 14, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 31.62, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 31.62, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 4.13, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 27.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 15, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 94.87, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 94.87, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "AD-1-4" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 16, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 63.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 63.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 8.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 55, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "77681" } } ], "itemSequence": 17, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 25.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 25.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 22, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 952.17, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 500, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 952.17, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 75.02, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/7c54b9cb-2f79-4c0c-a531-732dc4ac2756" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/b901366e-9ee4-4498-995f-b8a744725d94", "resource": { "resourceType": "Patient", "id": "b901366e-9ee4-4498-995f-b8a744725d94", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2378754283" } ], "active": true, "name": [ { "use": "official", "text": "sara Yaqoob gomaa Khan", "given": [ "sara", "gomaa", "Khan" ] } ], "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": "1999-02-08", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/73daa5f0-3a7b-4438-b0ff-aa76646f171a", "resource": { "resourceType": "Organization", "id": "73daa5f0-3a7b-4438-b0ff-aa76646f171a", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/c34f255e-d23c-4b03-b8fb-c1f531d6a12e", "resource": { "resourceType": "Organization", "id": "c34f255e-d23c-4b03-b8fb-c1f531d6a12e", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/7c54b9cb-2f79-4c0c-a531-732dc4ac2756", "resource": { "resourceType": "Coverage", "id": "7c54b9cb-2f79-4c0c-a531-732dc4ac2756", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "002437590256101" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/11e8c4ea-3954-444d-a56f-2bfd4f40fa6c" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/a7ff368a-1c85-4c0b-b9de-b8b98f409477" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/b901366e-9ee4-4498-995f-b8a744725d94" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/c34f255e-d23c-4b03-b8fb-c1f531d6a12e" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "55298177", "name": "ERAM LIMITED COMPANY" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/11e8c4ea-3954-444d-a56f-2bfd4f40fa6c", "resource": { "resourceType": "Organization", "id": "11e8c4ea-3954-444d-a56f-2bfd4f40fa6c", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/a7ff368a-1c85-4c0b-b9de-b8b98f409477", "resource": { "resourceType": "Patient", "id": "a7ff368a-1c85-4c0b-b9de-b8b98f409477", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2378754283" } ], "active": true, "name": [ { "use": "official", "text": "sara Yaqoob gomaa Khan", "given": [ "sara", "gomaa", "Khan" ] } ], "telecom": [ { "system": "phone", "value": "0565957203" } ], "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": "1999-02-08", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/29a3ef5a-3361-4d10-ba7d-cf16a4699f3b", "resource": { "resourceType": "Bundle", "id": "29a3ef5a-3361-4d10-ba7d-cf16a4699f3b", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:07.580+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/8b81bd5f-db08-443f-b8a6-e64814c06ab9", "resource": { "resourceType": "MessageHeader", "id": "8b81bd5f-db08-443f-b8a6-e64814c06ab9", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "2d29dafa-8560-4db0-ae8b-3e500705cbea", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/4a349ebd-e75e-4845-ac05-a64ffa21ff0d" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/4a349ebd-e75e-4845-ac05-a64ffa21ff0d", "resource": { "resourceType": "ClaimResponse", "id": "4a349ebd-e75e-4845-ac05-a64ffa21ff0d", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "159" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "4a349ebd-e75e-4845-ac05-a64ffa21ff0d" } ], "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": "https://tawuniya.com.sa/Patient/d28d8a57-4470-4713-9679-43d76176d6d1" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/568f2215-e7ce-4913-8b5b-39564e92ebf8" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/14310d1a-a04b-43b8-a0f3-d16c0762e938" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "52125498260902" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "76650" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/92cdc3db-981c-4c1e-9ae4-381178d03126" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/d28d8a57-4470-4713-9679-43d76176d6d1", "resource": { "resourceType": "Patient", "id": "d28d8a57-4470-4713-9679-43d76176d6d1", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2458928229" } ], "active": true, "name": [ { "use": "official", "text": "MOHAMMED ADEL AHMED ABDULRASHEED", "given": [ "MOHAMMED", "AHMED", "ABDULRASHEED" ] } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "2018-08-30", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/14310d1a-a04b-43b8-a0f3-d16c0762e938", "resource": { "resourceType": "Organization", "id": "14310d1a-a04b-43b8-a0f3-d16c0762e938", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/568f2215-e7ce-4913-8b5b-39564e92ebf8", "resource": { "resourceType": "Organization", "id": "568f2215-e7ce-4913-8b5b-39564e92ebf8", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/92cdc3db-981c-4c1e-9ae4-381178d03126", "resource": { "resourceType": "Coverage", "id": "92cdc3db-981c-4c1e-9ae4-381178d03126", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "002134730700211" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/b7066005-1f54-4ff8-9fa5-ff7393366c97" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/88c67695-1700-46e9-aa7b-948cbc42653f" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/d28d8a57-4470-4713-9679-43d76176d6d1" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/568f2215-e7ce-4913-8b5b-39564e92ebf8" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "58109032", "name": "MAAD INTERNATIONAL COMPANY LIMITED" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/b7066005-1f54-4ff8-9fa5-ff7393366c97", "resource": { "resourceType": "Organization", "id": "b7066005-1f54-4ff8-9fa5-ff7393366c97", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/88c67695-1700-46e9-aa7b-948cbc42653f", "resource": { "resourceType": "Patient", "id": "88c67695-1700-46e9-aa7b-948cbc42653f", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2458928229" } ], "active": true, "name": [ { "use": "official", "text": "MOHAMMED ADEL AHMED ABDULRASHEED", "given": [ "MOHAMMED", "AHMED", "ABDULRASHEED" ] } ], "telecom": [ { "system": "phone", "value": "0541271699" } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "2018-08-30", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/d312c2ee-a2f5-4b8a-8bf9-2e7c7669132a", "resource": { "resourceType": "Bundle", "id": "d312c2ee-a2f5-4b8a-8bf9-2e7c7669132a", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:05.937+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/716d2c42-f8ba-4045-8cda-cdba6080d32d", "resource": { "resourceType": "MessageHeader", "id": "716d2c42-f8ba-4045-8cda-cdba6080d32d", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "62b24a45-eb94-4928-b88f-38dbdc57b5f0", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/93e302f8-ec7d-493e-a050-9e7d9f282821" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/93e302f8-ec7d-493e-a050-9e7d9f282821", "resource": { "resourceType": "ClaimResponse", "id": "93e302f8-ec7d-493e-a050-9e7d9f282821", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "294" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "93e302f8-ec7d-493e-a050-9e7d9f282821" } ], "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": "https://tawuniya.com.sa/Patient/081d0d94-c919-4349-8d51-78f1ad78dcb6" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/a644c95a-e08a-4938-a79f-77be3b0833b3" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/41ef7581-25e5-4447-b755-2934ace80beb" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "49128625260905" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78193" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 92.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 66, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 16.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 92.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 9.9, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78193" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 22, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78193" } } ], "itemSequence": 3, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 49.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 5.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 49.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 35.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 8.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78193" } } ], "itemSequence": 4, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78193" } } ], "itemSequence": 5, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 22, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78193" } } ], "itemSequence": 6, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 15.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 2.75, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 15.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 11, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 1.65, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 246.68, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 176.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 44.05, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 246.68, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 26.43, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/73c61ccf-dc0b-465c-b1d5-230a6642c120" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/081d0d94-c919-4349-8d51-78f1ad78dcb6", "resource": { "resourceType": "Patient", "id": "081d0d94-c919-4349-8d51-78f1ad78dcb6", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1128005038" } ], "active": true, "name": [ { "use": "official", "text": "tala mostafa hasan SHARBINI", "given": [ "tala", "hasan", "SHARBINI" ] } ], "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": "2005-06-20", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/41ef7581-25e5-4447-b755-2934ace80beb", "resource": { "resourceType": "Organization", "id": "41ef7581-25e5-4447-b755-2934ace80beb", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/a644c95a-e08a-4938-a79f-77be3b0833b3", "resource": { "resourceType": "Organization", "id": "a644c95a-e08a-4938-a79f-77be3b0833b3", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/73c61ccf-dc0b-465c-b1d5-230a6642c120", "resource": { "resourceType": "Coverage", "id": "73c61ccf-dc0b-465c-b1d5-230a6642c120", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "001091641264111" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/b57fb06e-cb2d-4b4b-b1e0-e4010ad125f6" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/b788a95f-705c-4039-9ff4-dbf481546f11" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/081d0d94-c919-4349-8d51-78f1ad78dcb6" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/a644c95a-e08a-4938-a79f-77be3b0833b3" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "49737263", "name": "SULAIMAN ABDULLAH ALKHEREIJI CO" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/b57fb06e-cb2d-4b4b-b1e0-e4010ad125f6", "resource": { "resourceType": "Organization", "id": "b57fb06e-cb2d-4b4b-b1e0-e4010ad125f6", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/b788a95f-705c-4039-9ff4-dbf481546f11", "resource": { "resourceType": "Patient", "id": "b788a95f-705c-4039-9ff4-dbf481546f11", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1128005038" } ], "active": true, "name": [ { "use": "official", "text": "tala mostafa hasan SHARBINI", "given": [ "tala", "hasan", "SHARBINI" ] } ], "telecom": [ { "system": "phone", "value": "0568331310" } ], "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": "2005-06-20", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/42c3105a-087f-4e12-8f99-03d94b3bc58b", "resource": { "resourceType": "Bundle", "id": "42c3105a-087f-4e12-8f99-03d94b3bc58b", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:08.044+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/a61d065f-432e-4827-b008-7213bf4a5a1d", "resource": { "resourceType": "MessageHeader", "id": "a61d065f-432e-4827-b008-7213bf4a5a1d", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "2744416d-3c3e-4085-a688-3d7a1fe157aa", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/f9ebf930-684a-42f3-850c-1fae8e12c4a2" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/f9ebf930-684a-42f3-850c-1fae8e12c4a2", "resource": { "resourceType": "ClaimResponse", "id": "f9ebf930-684a-42f3-850c-1fae8e12c4a2", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "401" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "f9ebf930-684a-42f3-850c-1fae8e12c4a2" } ], "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": "https://tawuniya.com.sa/Patient/15ab7cf6-32c9-4384-9b07-aa81336c69d9" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/e315638a-211f-4fa3-8886-52d94ab3fe81" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/818cf412-c17e-48d6-bdf7-a6062eafe3c2" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "71131263260906" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79426" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/f8b02e4d-94af-4607-aa21-3e07878f687c" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/15ab7cf6-32c9-4384-9b07-aa81336c69d9", "resource": { "resourceType": "Patient", "id": "15ab7cf6-32c9-4384-9b07-aa81336c69d9", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1192664652" } ], "active": true, "name": [ { "use": "official", "text": "ghazi rayan ghazi KHAN", "given": [ "ghazi", "ghazi", "KHAN" ] } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "2019-05-31", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/818cf412-c17e-48d6-bdf7-a6062eafe3c2", "resource": { "resourceType": "Organization", "id": "818cf412-c17e-48d6-bdf7-a6062eafe3c2", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/e315638a-211f-4fa3-8886-52d94ab3fe81", "resource": { "resourceType": "Organization", "id": "e315638a-211f-4fa3-8886-52d94ab3fe81", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/f8b02e4d-94af-4607-aa21-3e07878f687c", "resource": { "resourceType": "Coverage", "id": "f8b02e4d-94af-4607-aa21-3e07878f687c", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "001065228643221" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/3c0bab2d-879f-487d-b7c0-036389da82b0" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/68be2297-9253-4362-bc27-1046969f7bac" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/15ab7cf6-32c9-4384-9b07-aa81336c69d9" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/e315638a-211f-4fa3-8886-52d94ab3fe81" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "33336", "name": "BANQUE SAUDI FRANSI" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/3c0bab2d-879f-487d-b7c0-036389da82b0", "resource": { "resourceType": "Organization", "id": "3c0bab2d-879f-487d-b7c0-036389da82b0", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/68be2297-9253-4362-bc27-1046969f7bac", "resource": { "resourceType": "Patient", "id": "68be2297-9253-4362-bc27-1046969f7bac", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "NI", "display": "National ID" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1192664652" } ], "active": true, "name": [ { "use": "official", "text": "ghazi rayan ghazi KHAN", "given": [ "ghazi", "ghazi", "KHAN" ] } ], "telecom": [ { "system": "phone", "value": "0565444998" } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "2019-05-31", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/40123d26-eb15-4550-93b0-8da190fc4bc3", "resource": { "resourceType": "Bundle", "id": "40123d26-eb15-4550-93b0-8da190fc4bc3", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:07.992+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/62d0e033-2e83-4aad-902b-582dfd0446c7", "resource": { "resourceType": "MessageHeader", "id": "62d0e033-2e83-4aad-902b-582dfd0446c7", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "9f58669b-d3ca-4a60-92eb-940f6ed47f21", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/2b2637bc-3cd6-437a-8c62-16a92d7d2c44" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/2b2637bc-3cd6-437a-8c62-16a92d7d2c44", "resource": { "resourceType": "ClaimResponse", "id": "2b2637bc-3cd6-437a-8c62-16a92d7d2c44", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "313" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "2b2637bc-3cd6-437a-8c62-16a92d7d2c44" } ], "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": "https://tawuniya.com.sa/Patient/6c859495-f71b-4e97-ac79-8d3955642821" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/163a63df-3e39-4070-a431-096e27de4344" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/2b56e50e-c674-48a6-b364-455ceccecb6a" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "23128969260905" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78347" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 35.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 49.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 5.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 8.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 49.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78347" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 80.08, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 14.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 80.08, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 57.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 8.58, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78347" } } ], "itemSequence": 3, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 157.36, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 112.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 28.1, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 157.36, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 16.86, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/2b161fda-6384-422d-baba-449fb679d04e" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/6c859495-f71b-4e97-ac79-8d3955642821", "resource": { "resourceType": "Patient", "id": "6c859495-f71b-4e97-ac79-8d3955642821", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2279262790" } ], "active": true, "name": [ { "use": "official", "text": "MOHAMMED ABDULMUTTELEB ABDULALEEM AZZOUZ", "given": [ "MOHAMMED", "ABDULALEEM", "AZZOUZ" ] } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "1976-09-08", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/2b56e50e-c674-48a6-b364-455ceccecb6a", "resource": { "resourceType": "Organization", "id": "2b56e50e-c674-48a6-b364-455ceccecb6a", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/163a63df-3e39-4070-a431-096e27de4344", "resource": { "resourceType": "Organization", "id": "163a63df-3e39-4070-a431-096e27de4344", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/2b161fda-6384-422d-baba-449fb679d04e", "resource": { "resourceType": "Coverage", "id": "2b161fda-6384-422d-baba-449fb679d04e", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "002279262790001" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/ee730e7a-057e-4bea-b165-b695660f219c" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/e5a8a5b0-9925-4242-bbff-67812d59a2d8" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/6c859495-f71b-4e97-ac79-8d3955642821" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/163a63df-3e39-4070-a431-096e27de4344" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "48800495", "name": "Almarefa school co Basic B" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/ee730e7a-057e-4bea-b165-b695660f219c", "resource": { "resourceType": "Organization", "id": "ee730e7a-057e-4bea-b165-b695660f219c", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/e5a8a5b0-9925-4242-bbff-67812d59a2d8", "resource": { "resourceType": "Patient", "id": "e5a8a5b0-9925-4242-bbff-67812d59a2d8", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2279262790" } ], "active": true, "name": [ { "use": "official", "text": "MOHAMMED ABDULMUTTELEB ABDULALEEM AZZOUZ", "given": [ "MOHAMMED", "ABDULALEEM", "AZZOUZ" ] } ], "telecom": [ { "system": "phone", "value": "0548451556" } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "1976-09-08", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/e3c3897b-e093-4211-89f4-176c4b7916a8", "resource": { "resourceType": "Bundle", "id": "e3c3897b-e093-4211-89f4-176c4b7916a8", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-20T11:52:08.017+03:00", "entry": [ { "fullUrl": "https://tawuniya.com.sa/MessageHeader/34f53d1f-98bf-4466-929e-6c961b712d90", "resource": { "resourceType": "MessageHeader", "id": "34f53d1f-98bf-4466-929e-6c961b712d90", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0" ] }, "eventCoding": { "system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events", "code": "claim-response" }, "destination": [ { "endpoint": "http://www.ALKholood.com", "receiver": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } } } ], "sender": { "type": "Organization", "identifier": { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } }, "source": { "endpoint": "https://tawuniya.com.sa" }, "response": { "identifier": "f6690a17-4a3a-4439-8e1b-2c3e40103336", "code": "ok" }, "focus": [ { "reference": "https://tawuniya.com.sa/ClaimResponse/c0d67dcd-0b91-4253-a6f3-f4b778d61c7a" } ] } }, { "fullUrl": "https://tawuniya.com.sa/ClaimResponse/c0d67dcd-0b91-4253-a6f3-f4b778d61c7a", "resource": { "resourceType": "ClaimResponse", "id": "c0d67dcd-0b91-4253-a6f3-f4b778d61c7a", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "partial" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "adjudication" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier", "valueIdentifier": { "system": "http://www.ALKholood.com/episode", "value": "393" } } ], "identifier": [ { "system": "https://tawuniya.com.sa/claimResponse", "value": "c0d67dcd-0b91-4253-a6f3-f4b778d61c7a" } ], "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": "https://tawuniya.com.sa/Patient/0cdcad8e-2aa2-402c-89df-4eb6ebcd5d79" }, "created": "2026-10-20", "insurer": { "reference": "https://tawuniya.com.sa/Organization/bf031327-cd4d-45cd-802e-983842d93526" }, "requestor": { "reference": "https://tawuniya.com.sa/Organization/cc811748-53f4-43b4-99b0-dbda541700d8" }, "request": { "identifier": { "system": "http://www.ALKholood.com/claim", "value": "66130984260906" } }, "outcome": "complete", "disposition": "-", "item": [ { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79292" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "AD-1-4" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79292" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 17.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 2.64, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 24.64, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 24.64, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 4.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79292" } } ], "itemSequence": 3, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 22, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79292" } } ], "itemSequence": 4, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79292" } } ], "itemSequence": 5, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 22, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.3, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79292" } } ], "itemSequence": 6, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "AD-1-4" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 15.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 15.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 2.75, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79292" } } ], "itemSequence": 7, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 49.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 8.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 49.28, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "AD-1-4" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 } ] }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome", "code": "approved" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "79292" } } ], "itemSequence": 8, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 61.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 11, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 61.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 44, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 6.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 271.32, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 125.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 48.45, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 271.32, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 18.84, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "https://tawuniya.com.sa/Coverage/a18f3c2b-453a-43aa-83b4-2fa79856fa51" } } ] } }, { "fullUrl": "https://tawuniya.com.sa/Patient/0cdcad8e-2aa2-402c-89df-4eb6ebcd5d79", "resource": { "resourceType": "Patient", "id": "0cdcad8e-2aa2-402c-89df-4eb6ebcd5d79", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2503595650" } ], "active": true, "name": [ { "use": "official", "text": "ALTEGANI HASAN MOHAMMED ALTAIB", "given": [ "ALTEGANI", "MOHAMMED", "ALTAIB" ] } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "1992-04-14", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "https://tawuniya.com.sa/Organization/cc811748-53f4-43b4-99b0-dbda541700d8", "resource": { "resourceType": "Organization", "id": "cc811748-53f4-43b4-99b0-dbda541700d8", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } }, { "fullUrl": "https://tawuniya.com.sa/Organization/bf031327-cd4d-45cd-802e-983842d93526", "resource": { "resourceType": "Organization", "id": "bf031327-cd4d-45cd-802e-983842d93526", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7000911508" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ], "name": "The Cooperative Company for Cooperative Insurance" } }, { "fullUrl": "https://tawuniya.com.sa/Coverage/a18f3c2b-453a-43aa-83b4-2fa79856fa51", "resource": { "resourceType": "Coverage", "id": "a18f3c2b-453a-43aa-83b4-2fa79856fa51", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "https://tawuniya.com.sa/memberid", "value": "002503595650001" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "https://tawuniya.com.sa/Organization/81d42a00-90d7-4677-9fc1-9c25e153fb98" }, "subscriber": { "reference": "https://tawuniya.com.sa/Patient/c242e14a-2170-498b-bc8a-988bff92b642" }, "beneficiary": { "reference": "https://tawuniya.com.sa/Patient/0cdcad8e-2aa2-402c-89df-4eb6ebcd5d79" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self", "display": "self" } ] }, "payor": [ { "reference": "https://tawuniya.com.sa/Organization/bf031327-cd4d-45cd-802e-983842d93526" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "57751321", "name": "TEAM CONSTRUCTION COMPANY LTD" } ] } }, { "fullUrl": "https://tawuniya.com.sa/Organization/81d42a00-90d7-4677-9fc1-9c25e153fb98", "resource": { "resourceType": "Organization", "id": "81d42a00-90d7-4677-9fc1-9c25e153fb98", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "active": true, "name": "Policy Holder" } }, { "fullUrl": "https://tawuniya.com.sa/Patient/c242e14a-2170-498b-bc8a-988bff92b642", "resource": { "resourceType": "Patient", "id": "c242e14a-2170-498b-bc8a-988bff92b642", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0" ] }, "extension": [ { "url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality", "valueCodeableConcept": { "coding": [ { "system": "https://nphies.sa/terminology/CodeSystem/nationality", "code": "PAK" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/religion", "code": "0", "display": "other" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/occupation", "code": "others", "display": "others" } ] } } ], "identifier": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRC", "display": "iqama" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2503595650" } ], "active": true, "name": [ { "use": "official", "text": "ALTEGANI HASAN MOHAMMED ALTAIB", "given": [ "ALTEGANI", "MOHAMMED", "ALTAIB" ] } ], "telecom": [ { "system": "phone", "value": "0568018772" } ], "gender": "male", "_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": "male", "display": "male" } ] } } ] }, "birthDate": "1992-04-14", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } } ] } }, { "fullUrl": "http://www.ALKholood.com/Organization/9", "resource": { "resourceType": "Organization", "id": "9", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0" ] }, "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/provider-type", "code": "5", "display": "Clinic" } ] } } ], "identifier": [ { "use": "official", "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ], "name": "Al-Kholood Medical Company - AlHaj" } } ] }