{ "resourceType": "Bundle", "id": "8f9714c9-320c-4b00-a0bd-92198b36561e", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-31T17:28:10.630+03:00", "entry": [ { "fullUrl": "http://nphies.sa/MessageHeader/b8fc9408-f268-4a11-b93d-eb1b841863d4", "resource": { "resourceType": "MessageHeader", "id": "b8fc9408-f268-4a11-b93d-eb1b841863d4", "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": "03e92a08-7d09-4b3c-b72a-7202fc64ee45", "code": "ok" } } }, { "fullUrl": "http://nphies.sa/Task/8bc195bb-654e-4953-aa5b-952ada916658", "resource": { "resourceType": "Task", "id": "8bc195bb-654e-4953-aa5b-952ada916658", "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": "991" } ], "status": "completed", "intent": "order", "priority": "stat", "code": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/task-code", "code": "poll" } ] }, "authoredOn": "2026-09-30", "lastModified": "2026-10-31", "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": "2026-09-30T00:00:00.000+03:00", "end": "2026-10-31T23:59:59.999+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": "2026-10-22T08:31:30.356+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/aceb2ad3-dd57-31c8-b67b-ab0ddb341aad" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:31.025+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/4d2035bf-5f01-5a0f-9fa9-d84f0fd74d73" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:32.184+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/2e679e4e-196f-1b76-99dd-545705d55462" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:32.835+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/778d8949-86b6-1d5d-87a8-cc6df0cbf906" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:33.478+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/5e607c20-a483-404c-9d3f-035a032b3c1e" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:34.171+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/89aefeb4-e1a1-5d67-8afa-9f1fa6926164" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:34.933+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/0c3f80a8-4603-4c68-a9c8-315fb51721ed" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:36.347+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/56db294a-3dee-4ae4-b8a1-6f802dbed908" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:37.044+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/919ee849-3387-4273-b966-a0edbf5468f2" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:31:37.702+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/d9362793-2528-5458-8df9-2846a1500305" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/aceb2ad3-dd57-31c8-b67b-ab0ddb341aad", "resource": { "resourceType": "Bundle", "id": "aceb2ad3-dd57-31c8-b67b-ab0ddb341aad", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:29.608+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/e14f39ce-edfd-2c11-bd81-f628b2cb6e17", "resource": { "resourceType": "MessageHeader", "id": "e14f39ce-edfd-2c11-bd81-f628b2cb6e17", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "e469f75e-8518-4681-afde-f562dc6e5ec9", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168847" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168847", "resource": { "resourceType": "ClaimResponse", "id": "168847", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710555" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "http://globemedsaudi.com/Patient/475370" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/475372" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/475371" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "18172897260922" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "95600" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 24, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 6, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 33.6, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 24, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 33.6, "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": "patientShare" } ] }, "amount": { "value": 6, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168848" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/475370", "resource": { "resourceType": "Patient", "id": "475370", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2028286736" } ], "active": true, "name": [ { "text": "AZIZA SALEH muhammad muhammad", "given": [ "AZIZA", "muhammad", "muhammad" ] } ], "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" } ] } } ] }, "birthDate": "1981-05-05", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168848", "resource": { "resourceType": "Coverage", "id": "168848", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44110234" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/475373" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/475370" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/475372" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2560750", "name": "Abdushakoor muhammad" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/475371", "resource": { "resourceType": "Organization", "id": "475371", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/475372", "resource": { "resourceType": "Organization", "id": "475372", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/475373", "resource": { "resourceType": "Organization", "id": "475373", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2560750" } ], "active": true, "name": "Abdushakoor muhammad" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/4d2035bf-5f01-5a0f-9fa9-d84f0fd74d73", "resource": { "resourceType": "Bundle", "id": "4d2035bf-5f01-5a0f-9fa9-d84f0fd74d73", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:30.676+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/ab0800a8-f8b5-216f-93d3-fd043eb3577b", "resource": { "resourceType": "MessageHeader", "id": "ab0800a8-f8b5-216f-93d3-fd043eb3577b", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "de1513a5-4c6f-49c3-bd0c-aafcca2f4caf", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168877" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168877", "resource": { "resourceType": "ClaimResponse", "id": "168877", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710564" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "http://globemedsaudi.com/Patient/444010" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/444012" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/444011" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "28234867260907" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "80835" } } ], "itemSequence": 1, "noteNumber": [ 1 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "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": "CV-1-4" }, { "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": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 29.95, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 37.44, "currency": "SAR" } } ] }, { "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": "80835" } } ], "itemSequence": 2, "noteNumber": [ 2 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "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": "CV-1-4" }, { "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": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 36.43, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 45.54, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "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": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 82.98, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 66.38, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "The Service Is Rejected Because Of Policy General Exclusion Related To Hair Loss" }, { "number": 1, "type": "display", "text": "The Drug Is Rejected Because It Is Not Considered As Medically Necessary" }, { "number": 2, "type": "display", "text": "The Drug Is Rejected Because It Is Not Considered As Medically Necessary" }, { "number": 2, "type": "display", "text": "The Service Is Rejected Because Of Policy General Exclusion Related To Hair Loss" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168878" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/444010", "resource": { "resourceType": "Patient", "id": "444010", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2639880067" } ], "active": true, "name": [ { "text": "asma gamal KEMAL", "given": [ "asma", "gamal", "KEMAL" ] } ], "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" } ] } } ] }, "birthDate": "2000-07-25", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168878", "resource": { "resourceType": "Coverage", "id": "168878", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44208179" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/444013" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/444010" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/444012" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2534894", "name": "Small Group-2534894" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/444011", "resource": { "resourceType": "Organization", "id": "444011", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/444012", "resource": { "resourceType": "Organization", "id": "444012", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/444013", "resource": { "resourceType": "Organization", "id": "444013", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2534894" } ], "active": true, "name": "Small Group-2534894" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/2e679e4e-196f-1b76-99dd-545705d55462", "resource": { "resourceType": "Bundle", "id": "2e679e4e-196f-1b76-99dd-545705d55462", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:31.395+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/4039d9e7-347f-4b1f-a898-bfa1bdec5cd6", "resource": { "resourceType": "MessageHeader", "id": "4039d9e7-347f-4b1f-a898-bfa1bdec5cd6", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "9d72f5b9-29db-4c08-a774-5e0b24d5eec6", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168897" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168897", "resource": { "resourceType": "ClaimResponse", "id": "168897", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710569" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "http://globemedsaudi.com/Patient/437442" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/437444" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/437443" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "43160861260917" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "90928" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 150, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 120, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 30, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 18, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 30, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 168, "currency": "SAR" } } ] }, { "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": "90928" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 60, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 48, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 7.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 67.2, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 168, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 210, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 42, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 25.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 235.2, "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": "patientShare" } ] }, "amount": { "value": 42, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168898" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/437442", "resource": { "resourceType": "Patient", "id": "437442", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2084514518" } ], "active": true, "name": [ { "text": "BASHAER ABDULHAQ ABDULHAQ ABDULHAQ", "given": [ "BASHAER", "ABDULHAQ", "ABDULHAQ" ] } ], "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" } ] } } ] }, "birthDate": "1992-03-06", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168898", "resource": { "resourceType": "Coverage", "id": "168898", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44110412" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/437445" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/437442" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/437444" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2570503", "name": "amen ebrahem" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/437443", "resource": { "resourceType": "Organization", "id": "437443", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/437444", "resource": { "resourceType": "Organization", "id": "437444", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/437445", "resource": { "resourceType": "Organization", "id": "437445", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2570503" } ], "active": true, "name": "amen ebrahem" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/778d8949-86b6-1d5d-87a8-cc6df0cbf906", "resource": { "resourceType": "Bundle", "id": "778d8949-86b6-1d5d-87a8-cc6df0cbf906", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:32.512+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/484d192d-c722-486f-b1b0-4af07d6bbed8", "resource": { "resourceType": "MessageHeader", "id": "484d192d-c722-486f-b1b0-4af07d6bbed8", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "b7e1da0c-6140-4485-85de-8f1548a71121", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168913" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168913", "resource": { "resourceType": "ClaimResponse", "id": "168913", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710574" } ], "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": "http://globemedsaudi.com/Patient/435211" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/435213" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/435212" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "29130218260905" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "78883" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 160, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 160, "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": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 2 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 24, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 184, "currency": "SAR" } } ] }, { "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": "78883" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 19, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 1, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 2.85, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 1, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 22.85, "currency": "SAR" } } ] }, { "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-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78883" } } ], "itemSequence": 3, "noteNumber": [ 1 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 72, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "BE-1-6" }, { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "BE-1-7" } ] }, "amount": { "value": 57.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 14.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 14.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 8.64, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 14.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 82.8, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 236.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 252, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 15.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 35.49, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 289.65, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 14.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 15.4, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "Wrong Vat Applied" }, { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168914" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/435211", "resource": { "resourceType": "Patient", "id": "435211", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2443721507" } ], "active": true, "name": [ { "text": "hanin abdrhman abdrhman", "given": [ "hanin", "abdrhman", "abdrhman" ] } ], "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" } ] } } ] }, "birthDate": "2017-05-07", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168914", "resource": { "resourceType": "Coverage", "id": "168914", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44108582" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/435214" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/435211" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/435213" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2535378", "name": "Small Group-2535378" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/435212", "resource": { "resourceType": "Organization", "id": "435212", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/435213", "resource": { "resourceType": "Organization", "id": "435213", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/435214", "resource": { "resourceType": "Organization", "id": "435214", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2535378" } ], "active": true, "name": "Small Group-2535378" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/5e607c20-a483-404c-9d3f-035a032b3c1e", "resource": { "resourceType": "Bundle", "id": "5e607c20-a483-404c-9d3f-035a032b3c1e", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:33.179+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/05fc2ace-e8d1-4caf-9b11-0d4b14be315c", "resource": { "resourceType": "MessageHeader", "id": "05fc2ace-e8d1-4caf-9b11-0d4b14be315c", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "bda54163-f107-4a08-80d8-a59f7b5dabb3", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168919" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168919", "resource": { "resourceType": "ClaimResponse", "id": "168919", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710577" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "http://globemedsaudi.com/Patient/433985" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/433987" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/433986" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "29125116260902" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "76497" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 132, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 105.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 26.4, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 15.84, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 26.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 147.84, "currency": "SAR" } } ] }, { "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": "76497" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 55, "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": "copay" } ] }, "amount": { "value": 11, "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 }, { "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": "patientShare" } ] }, "amount": { "value": 11, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 61.6, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 149.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 187, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 37.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 22.44, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 209.44, "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": "patientShare" } ] }, "amount": { "value": 37.4, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168920" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/433985", "resource": { "resourceType": "Patient", "id": "433985", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2634071522" } ], "active": true, "name": [ { "text": "SIF ALDEEN FAKHER ELDIN hamad", "given": [ "SIF ALDEEN", "FAKHER ELDIN", "hamad" ] } ], "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" } ] } } ] }, "birthDate": "2026-03-28", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168920", "resource": { "resourceType": "Coverage", "id": "168920", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44207980" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/433988" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/433985" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/433987" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2540324", "name": "Fawzia Mohsen Saad Al-Mutairi Contracting Company" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/433986", "resource": { "resourceType": "Organization", "id": "433986", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/433987", "resource": { "resourceType": "Organization", "id": "433987", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/433988", "resource": { "resourceType": "Organization", "id": "433988", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2540324" } ], "active": true, "name": "Fawzia Mohsen Saad Al-Mutairi Contracting Company" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/89aefeb4-e1a1-5d67-8afa-9f1fa6926164", "resource": { "resourceType": "Bundle", "id": "89aefeb4-e1a1-5d67-8afa-9f1fa6926164", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:33.845+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/b8db6529-e20d-5a47-858c-0a77fa69aa35", "resource": { "resourceType": "MessageHeader", "id": "b8db6529-e20d-5a47-858c-0a77fa69aa35", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "89f43d55-aef9-4545-bf13-d67bb0a6a98c", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168932" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168932", "resource": { "resourceType": "ClaimResponse", "id": "168932", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710581" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "http://globemedsaudi.com/Patient/443585" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/443587" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/443586" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "54225677260902" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "76734" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 16.87, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 13.49, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 3.38, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 3.38, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 16.87, "currency": "SAR" } } ] }, { "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": "76734" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 25.65, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 20.52, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 5.13, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 5.13, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 25.65, "currency": "SAR" } } ] }, { "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": "76734" } } ], "itemSequence": 3, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 22.23, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 17.78, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 4.45, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 4.45, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 22.23, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 51.79, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 64.75, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 12.96, "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": 64.75, "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": "patientShare" } ] }, "amount": { "value": 12.96, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168933" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/443585", "resource": { "resourceType": "Patient", "id": "443585", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2492804113" } ], "active": true, "name": [ { "text": "MOHAMMED AHMED YOUSSEF MAHMOUD", "given": [ "MOHAMMED", "YOUSSEF", "MAHMOUD" ] } ], "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" } ] } } ] }, "birthDate": "1993-01-23", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168933", "resource": { "resourceType": "Coverage", "id": "168933", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "43781567" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/443588" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/443585" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/443587" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2553001", "name": "Halool Khaliyawi Alqithami Restaurant For Local Cuisine" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/443586", "resource": { "resourceType": "Organization", "id": "443586", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/443587", "resource": { "resourceType": "Organization", "id": "443587", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/443588", "resource": { "resourceType": "Organization", "id": "443588", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2553001" } ], "active": true, "name": "Halool Khaliyawi Alqithami Restaurant For Local Cuisine" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/0c3f80a8-4603-4c68-a9c8-315fb51721ed", "resource": { "resourceType": "Bundle", "id": "0c3f80a8-4603-4c68-a9c8-315fb51721ed", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:34.565+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/a0397619-a5fe-1132-97ae-adccfdc4ce79", "resource": { "resourceType": "MessageHeader", "id": "a0397619-a5fe-1132-97ae-adccfdc4ce79", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "3fb8c567-9487-4b23-a301-3ad0d8b581df", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168952" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168952", "resource": { "resourceType": "ClaimResponse", "id": "168952", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710588" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "http://globemedsaudi.com/Patient/445648" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/445650" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/445649" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "75279859260926" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "98558" } } ], "itemSequence": 1, "noteNumber": [ 1 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "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": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 14.69, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 18.36, "currency": "SAR" } } ] }, { "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": "98558" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 7.11, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 5.69, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 1.42, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 1.42, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 7.11, "currency": "SAR" } } ] }, { "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": "98558" } } ], "itemSequence": 3, "noteNumber": [ 2 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "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": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 30.14, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 37.67, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 5.69, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 7.11, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 1.42, "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": 63.14, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 44.83, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 1.42, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "The Drug Is Rejected Because It Is Not Considered As Medically Necessary" }, { "number": 2, "type": "display", "text": "The Drug Is Rejected Because It Is Not Considered As Medically Necessary" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168953" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/445648", "resource": { "resourceType": "Patient", "id": "445648", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2553647211" } ], "active": true, "name": [ { "text": "WISAM USAMA ALNDAF ALNADAF", "given": [ "WISAM", "ALNDAF", "ALNADAF" ] } ], "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" } ] } } ] }, "birthDate": "2021-09-21", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168953", "resource": { "resourceType": "Coverage", "id": "168953", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44856441" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/445651" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/445648" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/445650" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2581065", "name": "BAAN BAKERY COMPANY FOR BREAD" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/445649", "resource": { "resourceType": "Organization", "id": "445649", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/445650", "resource": { "resourceType": "Organization", "id": "445650", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/445651", "resource": { "resourceType": "Organization", "id": "445651", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2581065" } ], "active": true, "name": "BAAN BAKERY COMPANY FOR BREAD" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/56db294a-3dee-4ae4-b8a1-6f802dbed908", "resource": { "resourceType": "Bundle", "id": "56db294a-3dee-4ae4-b8a1-6f802dbed908", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:35.893+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/81913ff8-38c9-2b54-98ac-49e0a8c87435", "resource": { "resourceType": "MessageHeader", "id": "81913ff8-38c9-2b54-98ac-49e0a8c87435", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "9c019fe5-4da4-46fe-aab9-1122467c993a", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168981" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168981", "resource": { "resourceType": "ClaimResponse", "id": "168981", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue", "valueCodeableConcept": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/reissue-reason", "code": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710595" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "http://globemedsaudi.com/Patient/434769" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/434771" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/434770" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "27126801260903" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "77304" } } ], "itemSequence": 1, "noteNumber": [ 1 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "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": "CV-1-9" } ] }, "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": "deductible" } ] }, "amount": { "value": 32, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 0 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 44.8, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "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": "tax" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 44.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 32, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "Follow Up Consultation Same Complaint" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168982" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/434769", "resource": { "resourceType": "Patient", "id": "434769", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2505780797" } ], "active": true, "name": [ { "text": "HAFID Mujahid MOHAMAD", "given": [ "HAFID", "Mujahid", "MOHAMAD" ] } ], "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" } ] } } ] }, "birthDate": "2000-01-12", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168982", "resource": { "resourceType": "Coverage", "id": "168982", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "43793381" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/434772" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/434769" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/434771" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2545597", "name": "Small Group-2545597" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/434770", "resource": { "resourceType": "Organization", "id": "434770", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/434771", "resource": { "resourceType": "Organization", "id": "434771", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/434772", "resource": { "resourceType": "Organization", "id": "434772", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2545597" } ], "active": true, "name": "Small Group-2545597" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/919ee849-3387-4273-b966-a0edbf5468f2", "resource": { "resourceType": "Bundle", "id": "919ee849-3387-4273-b966-a0edbf5468f2", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:36.732+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/dff2dfc3-9cee-3a4a-95a4-1c4b5893c223", "resource": { "resourceType": "MessageHeader", "id": "dff2dfc3-9cee-3a4a-95a4-1c4b5893c223", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "297f4b6a-a544-49f9-b0f1-ea6362ebdd47", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168992" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168992", "resource": { "resourceType": "ClaimResponse", "id": "168992", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710598" } ], "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": "http://globemedsaudi.com/Patient/433836" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/433838" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/433837" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "24122666260901" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "75404" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 20, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 16, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 2.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 22.4, "currency": "SAR" } } ] }, { "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": "75404" } } ], "itemSequence": 2, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 72, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 57.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 14.4, "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 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 8.64, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 14.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 80.64, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 73.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 92, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 18.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 11.04, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 103.04, "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": "patientShare" } ] }, "amount": { "value": 18.4, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168993" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/433836", "resource": { "resourceType": "Patient", "id": "433836", "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" } ] }, "system": "http://nphies.sa/identifier/nationalid", "value": "1096128507" } ], "active": true, "name": [ { "text": "MAGED SALEH MOHAMMED ALSANARY", "given": [ "MAGED", "MOHAMMED", "ALSANARY" ] } ], "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" } ] } } ] }, "birthDate": "1997-08-23", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168993", "resource": { "resourceType": "Coverage", "id": "168993", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44064475" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/433839" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/433836" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/433838" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2575871", "name": "alwahdat alkhassa company ltd." } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/433837", "resource": { "resourceType": "Organization", "id": "433837", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/433838", "resource": { "resourceType": "Organization", "id": "433838", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/433839", "resource": { "resourceType": "Organization", "id": "433839", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2575871" } ], "active": true, "name": "alwahdat alkhassa company ltd." } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/d9362793-2528-5458-8df9-2846a1500305", "resource": { "resourceType": "Bundle", "id": "d9362793-2528-5458-8df9-2846a1500305", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:31:37.407+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/2adc20e4-58e9-28a4-ac76-c8a4faf7f870", "resource": { "resourceType": "MessageHeader", "id": "2adc20e4-58e9-28a4-ac76-c8a4faf7f870", "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://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/payer-license", "value": "7001463160" } }, "source": { "endpoint": "http://nphies.sa/license/payer-license/7001463160" }, "response": { "identifier": "d4b15955-c746-4b6f-a2ce-a01c206921f2", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/169009" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/169009", "resource": { "resourceType": "ClaimResponse", "id": "169009", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-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": "audit" } ] } } ], "identifier": [ { "system": "http://globemedsaudi.com/ClaimResponse/", "value": "147710603" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional" } ] }, "subType": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/claim-subtype", "code": "op" } ] }, "use": "claim", "patient": { "reference": "http://globemedsaudi.com/Patient/437896" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/437898" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/437897" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "18168121260921" } }, "outcome": "complete", "payeeType": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "provider" } ] }, "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": "partial" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "93912" } } ], "itemSequence": 1, "noteNumber": [ 1 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "reason": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "BE-1-6" }, { "system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason", "code": "BE-1-7" } ] }, "amount": { "value": 24, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 34.35, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 24, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 30, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 3.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 34.35, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 6, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "Wrong Vat Applied" }, { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/169010" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/437896", "resource": { "resourceType": "Patient", "id": "437896", "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" } ] }, "system": "http://nphies.sa/identifier/iqama", "value": "2491719536" } ], "active": true, "name": [ { "text": "ZOBEDh ismail GAMURALDEEN", "given": [ "ZOBEDh", "ismail", "GAMURALDEEN" ] } ], "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" } ] } } ] }, "birthDate": "2020-02-12", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/169010", "resource": { "resourceType": "Coverage", "id": "169010", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44157499" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/437899" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/437896" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/437898" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2546607", "name": "Small Group-2546607" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/437897", "resource": { "resourceType": "Organization", "id": "437897", "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" } ] } } ], "identifier": [ { "system": "http://nphies.sa/license/provider-license", "value": "10000300062591" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "prov" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/437898", "resource": { "resourceType": "Organization", "id": "437898", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/payer-license", "value": "7001549059" } ], "active": true, "type": [ { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/organization-type", "code": "ins" } ] } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/437899", "resource": { "resourceType": "Organization", "id": "437899", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2546607" } ], "active": true, "name": "Small Group-2546607" } } ] } }, { "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" } } ] }