{ "resourceType": "Bundle", "id": "63c55fc5-2c3f-4e58-8fd0-c5ab59053a64", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-31T17:05:03.847+03:00", "entry": [ { "fullUrl": "http://nphies.sa/MessageHeader/ab882067-3cc6-4573-a349-0c3303bb1a05", "resource": { "resourceType": "MessageHeader", "id": "ab882067-3cc6-4573-a349-0c3303bb1a05", "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": "39b927d7-70d2-4489-a8d0-0f52bcf63e15", "code": "ok" } } }, { "fullUrl": "http://nphies.sa/Task/d65c5a9f-9eee-4400-a7e3-3cc0ac7e657a", "resource": { "resourceType": "Task", "id": "d65c5a9f-9eee-4400-a7e3-3cc0ac7e657a", "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": "236" } ], "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": "2026-10-22T08:30:42.849+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/3eb4d177-4468-343c-bfed-edd8480035e5" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:43.537+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/8c90cfdb-3e42-3b47-a9eb-4ccf9067a5a4" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:45.710+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/cac2ca6d-0d69-1eaf-bfd6-401ad88e36a9" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:47.225+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/6a5aecb0-b64b-1996-8326-4448851e62fc" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:48.232+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/e5dc0918-c23f-1dc4-b4af-9643ee266cda" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:49.077+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/8e7b6d40-be0d-39ff-9783-1fb0484ab589" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:49.785+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/a68c1cbe-ca4d-3ad6-ab79-24c217f3f361" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:50.369+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/2be80eca-d63f-369e-83e2-b23950e1bdb2" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:51.102+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/7136e5b6-0c38-51ca-8a55-67a808e00e98" } }, { "extension": [ { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp", "valueDateTime": "2026-10-22T08:30:51.884+00:00" } ], "type": { "coding": [ { "system": "http://nphies.sa/terminology/ValueSet/task-output-type", "code": "response" } ] }, "valueReference": { "reference": "http://nphies.sa/Bundle/9ed1b2a7-baf5-5b83-8ee2-ad9c25aec10f" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/3eb4d177-4468-343c-bfed-edd8480035e5", "resource": { "resourceType": "Bundle", "id": "3eb4d177-4468-343c-bfed-edd8480035e5", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:42.560+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/7cfe0789-1a30-3547-a971-32b9a4c633f6", "resource": { "resourceType": "MessageHeader", "id": "7cfe0789-1a30-3547-a971-32b9a4c633f6", "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": "d8b6a4d0-fb5e-46c3-9ea5-9aa04cc9c9bf", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168197" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168197", "resource": { "resourceType": "ClaimResponse", "id": "168197", "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": "147710346" } ], "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/436511" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/436513" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/436512" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "2141277260910" } }, "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": "83375" } } ], "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": 150, "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": 1 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 22.5, "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": 172.5, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 150, "currency": "SAR" } }, { "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": "copay" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 22.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 172.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 0, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168198" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/436511", "resource": { "resourceType": "Patient", "id": "436511", "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": "1079298830" } ], "active": true, "name": [ { "text": "NORAH SALEM alfahmi", "given": [ "NORAH", "SALEM", "alfahmi" ] } ], "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": "1989-03-08", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168198", "resource": { "resourceType": "Coverage", "id": "168198", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "43727837" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/436514" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/436511" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/436513" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2574742", "name": "Small Group-2574742" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/436512", "resource": { "resourceType": "Organization", "id": "436512", "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/436513", "resource": { "resourceType": "Organization", "id": "436513", "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/436514", "resource": { "resourceType": "Organization", "id": "436514", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2574742" } ], "active": true, "name": "Small Group-2574742" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/8c90cfdb-3e42-3b47-a9eb-4ccf9067a5a4", "resource": { "resourceType": "Bundle", "id": "8c90cfdb-3e42-3b47-a9eb-4ccf9067a5a4", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:43.261+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/d7e66522-b869-15bd-a757-52f59d4a8e8f", "resource": { "resourceType": "MessageHeader", "id": "d7e66522-b869-15bd-a757-52f59d4a8e8f", "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": "34091727-99d6-438e-9eec-1917a9d70789", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168211" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168211", "resource": { "resourceType": "ClaimResponse", "id": "168211", "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": "147710349" } ], "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/439097" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/439099" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/439098" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "34187956260928" } }, "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": "101245" } } ], "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" } } ] } ], "total": [ { "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": "eligible" } ] }, "amount": { "value": 20, "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": "tax" } ] }, "amount": { "value": 2.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 22.4, "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": "patientShare" } ] }, "amount": { "value": 4, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168212" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/439097", "resource": { "resourceType": "Patient", "id": "439097", "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": "2490557168" } ], "active": true, "name": [ { "text": "LMAR raed alsharaif", "given": [ "LMAR", "raed", "alsharaif" ] } ], "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": "2018-11-26", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168212", "resource": { "resourceType": "Coverage", "id": "168212", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "43761186" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/439100" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/439097" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/439099" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2560517", "name": "Mohammed Ali Bin Ahmed Al Ghamdi Trading Establishment" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/439098", "resource": { "resourceType": "Organization", "id": "439098", "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/439099", "resource": { "resourceType": "Organization", "id": "439099", "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/439100", "resource": { "resourceType": "Organization", "id": "439100", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2560517" } ], "active": true, "name": "Mohammed Ali Bin Ahmed Al Ghamdi Trading Establishment" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/cac2ca6d-0d69-1eaf-bfd6-401ad88e36a9", "resource": { "resourceType": "Bundle", "id": "cac2ca6d-0d69-1eaf-bfd6-401ad88e36a9", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:43.908+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/9e9fa4c4-bf58-3619-8c7a-1d87237a8db7", "resource": { "resourceType": "MessageHeader", "id": "9e9fa4c4-bf58-3619-8c7a-1d87237a8db7", "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": "b5e5df65-dcfb-467c-83fe-1cf014d2f633", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168219" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168219", "resource": { "resourceType": "ClaimResponse", "id": "168219", "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": "147710351" } ], "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/435454" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/435456" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/435455" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "16128927260905" } }, "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": "78322" } } ], "itemSequence": 1, "noteNumber": [ 1 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 96, "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": 76.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 19.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 19.2, "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": 11.52, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 19.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 110.4, "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": "partial" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78322" } } ], "itemSequence": 2, "noteNumber": [ 2 ], "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": 6, "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": 34.5, "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": "78322" } } ], "itemSequence": 3, "noteNumber": [ 3 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 96, "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": 76.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 19.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 19.2, "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": 11.52, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 19.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 110.4, "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": "partial" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "78322" } } ], "itemSequence": 4, "noteNumber": [ 4 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 24, "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": 19.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 4.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 4.8, "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": 2.88, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 4.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 27.6, "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": "78322" } } ], "itemSequence": 5, "noteNumber": [ 5 ], "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": 220.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 276, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 55.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 33.12, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 317.25, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 54.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 55.2, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 1, "type": "display", "text": "Wrong Vat Applied" }, { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 2, "type": "display", "text": "Wrong Vat Applied" }, { "number": 2, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 2, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 3, "type": "display", "text": "Wrong Vat Applied" }, { "number": 3, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 3, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 4, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 4, "type": "display", "text": "Wrong Vat Applied" }, { "number": 4, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 5, "type": "display", "text": "Wrong Vat Applied" }, { "number": 5, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 5, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168220" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/435454", "resource": { "resourceType": "Patient", "id": "435454", "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": "2493134320" } ], "active": true, "name": [ { "text": "MOHAMMED ABED ABDULAZIZ ABEED", "given": [ "MOHAMMED", "ABDULAZIZ", "ABEED" ] } ], "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": "1995-08-12", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168220", "resource": { "resourceType": "Coverage", "id": "168220", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "43797920" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/435457" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/435454" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/435456" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2541997", "name": "Small Group-2541997" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/435455", "resource": { "resourceType": "Organization", "id": "435455", "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/435456", "resource": { "resourceType": "Organization", "id": "435456", "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/435457", "resource": { "resourceType": "Organization", "id": "435457", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2541997" } ], "active": true, "name": "Small Group-2541997" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/6a5aecb0-b64b-1996-8326-4448851e62fc", "resource": { "resourceType": "Bundle", "id": "6a5aecb0-b64b-1996-8326-4448851e62fc", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:46.170+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/dd9aedde-b9dc-5e9e-a0d1-0504feb080e5", "resource": { "resourceType": "MessageHeader", "id": "dd9aedde-b9dc-5e9e-a0d1-0504feb080e5", "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": "c82da6a6-2374-4df7-9cb8-3bc2fc897f95", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168231" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168231", "resource": { "resourceType": "ClaimResponse", "id": "168231", "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": "147710353" } ], "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/438758" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/438760" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/438759" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "11179071260926" } }, "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": "98195" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 18, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 14.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 3.6, "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": 2.16, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 3.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 20.16, "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": "98195" } } ], "itemSequence": 2, "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": "rejected" } ] } }, { "url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice", "valueIdentifier": { "system": "http://www.ALKholood.com/patientInvoice", "value": "98195" } } ], "itemSequence": 3, "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": 38.4, "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": 53.76, "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": "98195" } } ], "itemSequence": 4, "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" } } ] }, { "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": "98195" } } ], "itemSequence": 5, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 24, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 19.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 4.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 2.88, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 4.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 26.88, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 183.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 229, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 45.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 27.48, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 310.24, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 38.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 45.8, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "The ItemService Is Rejected Because It Is Not Considered As Medically Necessary" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168232" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/438758", "resource": { "resourceType": "Patient", "id": "438758", "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": "2141239653" } ], "active": true, "name": [ { "text": "HAJIRA abdulmajed Khan MUHAMMAD", "given": [ "HAJIRA", "Khan", "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": "1978-12-01", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168232", "resource": { "resourceType": "Coverage", "id": "168232", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44110550" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/438761" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/438758" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/438760" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2545125", "name": "Small Group-2545125" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/438759", "resource": { "resourceType": "Organization", "id": "438759", "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/438760", "resource": { "resourceType": "Organization", "id": "438760", "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/438761", "resource": { "resourceType": "Organization", "id": "438761", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2545125" } ], "active": true, "name": "Small Group-2545125" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/e5dc0918-c23f-1dc4-b4af-9643ee266cda", "resource": { "resourceType": "Bundle", "id": "e5dc0918-c23f-1dc4-b4af-9643ee266cda", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:47.703+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/ae2ef769-b211-5b22-bdeb-197af8818e59", "resource": { "resourceType": "MessageHeader", "id": "ae2ef769-b211-5b22-bdeb-197af8818e59", "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": "b26f6fce-ef6e-4833-8b76-815481f7088d", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168247" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168247", "resource": { "resourceType": "ClaimResponse", "id": "168247", "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": "147710357" } ], "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/436750" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/436752" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/436751" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "47146450260912" } }, "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": "85453" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 180, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 144, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 36, "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": 21.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 36, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 201.6, "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": "85453" } } ], "itemSequence": 2, "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" } } ] }, { "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": "85453" } } ], "itemSequence": 3, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 48, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 38.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 9.6, "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": 5.76, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 9.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 53.76, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 206.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 258, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 51.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 30.96, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 288.96, "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": 51.6, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168248" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/436750", "resource": { "resourceType": "Patient", "id": "436750", "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/168248", "resource": { "resourceType": "Coverage", "id": "168248", "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/436753" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/436750" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/436752" } ], "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/436751", "resource": { "resourceType": "Organization", "id": "436751", "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/436752", "resource": { "resourceType": "Organization", "id": "436752", "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/436753", "resource": { "resourceType": "Organization", "id": "436753", "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/8e7b6d40-be0d-39ff-9783-1fb0484ab589", "resource": { "resourceType": "Bundle", "id": "8e7b6d40-be0d-39ff-9783-1fb0484ab589", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:48.796+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/e94bdc75-c750-56ab-9f8c-26f53edcd272", "resource": { "resourceType": "MessageHeader", "id": "e94bdc75-c750-56ab-9f8c-26f53edcd272", "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": "0c31d759-ab97-4497-9c69-c36ff19273da", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168258" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168258", "resource": { "resourceType": "ClaimResponse", "id": "168258", "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": "147710360" } ], "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/438022" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/438024" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/438023" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "72171537260922" } }, "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": "95148" } } ], "itemSequence": 1, "noteNumber": [ 1 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 40, "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": 32, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 7, "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": 4.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 45.85, "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": "95148" } } ], "itemSequence": 2, "noteNumber": [ 2 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 48, "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": 38.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 9.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 9.6, "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": 5.76, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 9.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 55.2, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 70.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 88, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 17.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 10.56, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 101.05, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 16.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 17.6, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 1, "type": "display", "text": "Wrong Vat Applied" }, { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 2, "type": "display", "text": "Wrong Vat Applied" }, { "number": 2, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 2, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168259" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/438022", "resource": { "resourceType": "Patient", "id": "438022", "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": "2602094498" } ], "active": true, "name": [ { "text": "tareq muhammad fakri Khalid", "given": [ "tareq", "fakri", "Khalid" ] } ], "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": "2022-07-25", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "U" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168259", "resource": { "resourceType": "Coverage", "id": "168259", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44208899" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/438025" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/438022" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/438024" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2562189", "name": "Small Group-2562189" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/438023", "resource": { "resourceType": "Organization", "id": "438023", "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/438024", "resource": { "resourceType": "Organization", "id": "438024", "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/438025", "resource": { "resourceType": "Organization", "id": "438025", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2562189" } ], "active": true, "name": "Small Group-2562189" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/a68c1cbe-ca4d-3ad6-ab79-24c217f3f361", "resource": { "resourceType": "Bundle", "id": "a68c1cbe-ca4d-3ad6-ab79-24c217f3f361", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:49.421+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/b0287f85-5a84-17fe-ab3b-9db69849f3da", "resource": { "resourceType": "MessageHeader", "id": "b0287f85-5a84-17fe-ab3b-9db69849f3da", "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": "e5bb1831-5cb7-4ae4-8d13-d3cc68de2efc", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168260" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168260", "resource": { "resourceType": "ClaimResponse", "id": "168260", "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": "147710361" } ], "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/436001" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/436003" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/436002" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "86134824260907" } }, "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": "80822" } } ], "itemSequence": 1, "noteNumber": [ 1 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 48, "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": 38.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 9.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 9.6, "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": 5.76, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 9.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 55.2, "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": "80822" } } ], "itemSequence": 2, "noteNumber": [ 2 ], "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 39, "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": 31.2, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 7.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 7.8, "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": 4.68, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 7.8, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 44.85, "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": "80822" } } ], "itemSequence": 3, "noteNumber": [ 3 ], "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" } ] }, "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": 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": 10, "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": 63.1, "currency": "SAR" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 113.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 142, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 28.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 17.04, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 163.15, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 27.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 28.4, "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" }, { "number": 2, "type": "display", "text": "Wrong Vat Applied" }, { "number": 2, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 2, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 3, "type": "display", "text": "Wrong Vat Applied" }, { "number": 3, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 3, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168261" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/436001", "resource": { "resourceType": "Patient", "id": "436001", "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/168261", "resource": { "resourceType": "Coverage", "id": "168261", "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/436004" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/436001" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/436003" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2534894", "name": "Small Group-2534894" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/436002", "resource": { "resourceType": "Organization", "id": "436002", "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/436003", "resource": { "resourceType": "Organization", "id": "436003", "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/436004", "resource": { "resourceType": "Organization", "id": "436004", "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/2be80eca-d63f-369e-83e2-b23950e1bdb2", "resource": { "resourceType": "Bundle", "id": "2be80eca-d63f-369e-83e2-b23950e1bdb2", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:50.116+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/fceacaab-8634-46bd-89d5-718ea84efd64", "resource": { "resourceType": "MessageHeader", "id": "fceacaab-8634-46bd-89d5-718ea84efd64", "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": "ae23888e-6ec5-4fdc-b14f-90abc81d3b07", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168273" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168273", "resource": { "resourceType": "ClaimResponse", "id": "168273", "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": "147710364" } ], "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/438934" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/438936" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/438935" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "25178964260926" } }, "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": "98110" } } ], "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/168274" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/438934", "resource": { "resourceType": "Patient", "id": "438934", "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": "2227040108" } ], "active": true, "name": [ { "text": "MOHAMMED ABRAHEM GURSE", "given": [ "MOHAMMED", "ABRAHEM", "GURSE" ] } ], "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": "1988-01-01", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168274", "resource": { "resourceType": "Coverage", "id": "168274", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "43751999" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/438937" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/438934" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/438936" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2566341", "name": "Small Group-2566341" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/438935", "resource": { "resourceType": "Organization", "id": "438935", "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/438936", "resource": { "resourceType": "Organization", "id": "438936", "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/438937", "resource": { "resourceType": "Organization", "id": "438937", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2566341" } ], "active": true, "name": "Small Group-2566341" } } ] } }, { "fullUrl": "http://nphies.sa/Bundle/7136e5b6-0c38-51ca-8a55-67a808e00e98", "resource": { "resourceType": "Bundle", "id": "7136e5b6-0c38-51ca-8a55-67a808e00e98", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:50.729+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/8ec01f1e-c2ed-4302-acda-1e4fe40f51d8", "resource": { "resourceType": "MessageHeader", "id": "8ec01f1e-c2ed-4302-acda-1e4fe40f51d8", "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": "0d679931-d97a-4ff6-b089-ce03cbc2f888", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168275" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168275", "resource": { "resourceType": "ClaimResponse", "id": "168275", "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": "147710365" } ], "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/437242" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/437244" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/437243" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "81155110260915" } }, "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": "88805" } } ], "itemSequence": 1, "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": 44, "currency": "SAR" } }, { "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": "copay" } ] }, "amount": { "value": 11, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 6.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 61.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 11, "currency": "SAR" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168276" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/437242", "resource": { "resourceType": "Patient", "id": "437242", "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/168276", "resource": { "resourceType": "Coverage", "id": "168276", "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/437245" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/437242" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/437244" } ], "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/437243", "resource": { "resourceType": "Organization", "id": "437243", "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/437244", "resource": { "resourceType": "Organization", "id": "437244", "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/437245", "resource": { "resourceType": "Organization", "id": "437245", "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/9ed1b2a7-baf5-5b83-8ee2-ad9c25aec10f", "resource": { "resourceType": "Bundle", "id": "9ed1b2a7-baf5-5b83-8ee2-ad9c25aec10f", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0" ] }, "type": "message", "timestamp": "2026-10-22T11:30:51.482+03:00", "entry": [ { "fullUrl": "http://globemedsaudi.com/MessageHeader/c8fed3b1-e885-20e5-9ed0-f55dd328cec7", "resource": { "resourceType": "MessageHeader", "id": "c8fed3b1-e885-20e5-9ed0-f55dd328cec7", "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": "8aebcfa2-e110-48fe-8e51-6b7c8244f12e", "code": "ok" }, "focus": [ { "reference": "http://globemedsaudi.com/ClaimResponse/168285" } ] } }, { "fullUrl": "http://globemedsaudi.com/ClaimResponse/168285", "resource": { "resourceType": "ClaimResponse", "id": "168285", "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": "147710369" } ], "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/434236" }, "created": "2026-10-22", "insurer": { "reference": "http://globemedsaudi.com/Organization/434238" }, "requestor": { "reference": "http://globemedsaudi.com/Organization/434237" }, "request": { "type": "Claim", "identifier": { "system": "http://www.ALKholood.com/claim", "value": "3124833260902" } }, "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": "76364" } } ], "itemSequence": 1, "adjudication": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 450, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 394.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 55.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 59.17, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 55.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 509.17, "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": "76364" } } ], "itemSequence": 2, "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" } } ] }, { "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": "76364" } } ], "itemSequence": 3, "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": 131.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 18.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "deductible" } ] }, "amount": { "value": 0, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "approved-quantity" } ] }, "value": 1 }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 19.72, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication", "code": "patientShare" } ] }, "amount": { "value": 18.5, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 169.72, "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": "76364" } } ], "itemSequence": 4, "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" } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "benefit" } ] }, "amount": { "value": 602.6, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "eligible" } ] }, "amount": { "value": 692, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "copay" } ] }, "amount": { "value": 89.4, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "tax" } ] }, "amount": { "value": 90.38, "currency": "SAR" } }, { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] }, "amount": { "value": 784.54, "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": 89.4, "currency": "SAR" } } ], "processNote": [ { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" }, { "number": 1, "type": "display", "text": "Wrong Vat Applied" }, { "number": 1, "type": "display", "text": "Wrong Calculation Of The PatientS Deductable" } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "http://globemedsaudi.com/Coverage/168286" } } ] } }, { "fullUrl": "http://globemedsaudi.com/Patient/434236", "resource": { "resourceType": "Patient", "id": "434236", "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": "1029266150" } ], "active": true, "name": [ { "text": "MARIEM MOHSEN SALEH ALZAHRANI", "given": [ "MARIEM", "SALEH", "ALZAHRANI" ] } ], "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": "1975-07-10", "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M" } ] } } }, { "fullUrl": "http://globemedsaudi.com/Coverage/168286", "resource": { "resourceType": "Coverage", "id": "168286", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0" ] }, "identifier": [ { "system": "http://payer.com/memberid", "value": "44202099" } ], "status": "active", "type": { "coding": [ { "system": "http://nphies.sa/terminology/CodeSystem/coverage-type", "code": "EHCPOL" } ] }, "policyHolder": { "reference": "http://globemedsaudi.com/Organization/434239" }, "beneficiary": { "reference": "http://globemedsaudi.com/Patient/434236" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code": "self" } ] }, "payor": [ { "reference": "http://globemedsaudi.com/Organization/434238" } ], "class": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "plan" } ] }, "value": "2574672", "name": "HERITAGE ORIENTAL CA-2574672" } ] } }, { "fullUrl": "http://globemedsaudi.com/Organization/434237", "resource": { "resourceType": "Organization", "id": "434237", "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/434238", "resource": { "resourceType": "Organization", "id": "434238", "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/434239", "resource": { "resourceType": "Organization", "id": "434239", "meta": { "profile": [ "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0" ] }, "identifier": [ { "system": "http://nphies.sa/license/organization-license", "value": "2574672" } ], "active": true, "name": "HERITAGE ORIENTAL CA-2574672" } } ] } }, { "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" } } ] }