Error Al-Kholood Medical Company - AlHaj claim-response
All traces- Trace
- c6dee869-5eb5-4e69-bc02-1c48f152a305
- Started
- 2026-10-24 15:48:45.532 +03:00
- Branch
- Al-Kholood Medical Company - AlHaj (9)
- Mode
- Middleware
- Service URL
- https://nphies.careofme.net/api/v1/nphies/send
- HTTP
- 200 in 1312 ms
- Bundle / Request
- bc5fc905-ac4c-45f2-bea5-e578a8623449 / 583924
- Parsed items
- 0
- Total duration
- 1315 ms
- Error
- Cannot open database "NitcoSysLog" requested by the login. The login failed. Login failed for user 'NitcoWebcenter'.
{
"resourceType": "Bundle",
"id": "bc5fc905-ac4c-45f2-bea5-e578a8623449",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-24T15:48:45.53\u002B03:00",
"entry": [
{
"fullUrl": "urn:uuid:7b4507a5-dbb0-4f27-ac1e-2f31da31b36a",
"resource": {
"resourceType": "MessageHeader",
"id": "7b4507a5-dbb0-4f27-ac1e-2f31da31b36a",
"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": "poll-request"
},
"destination": [
{
"endpoint": "http://nphies.sa",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/nphies",
"value": "NPHIES"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
},
"source": {
"endpoint": "http://nphies.sa/license/provider-license/10000300062591"
},
"focus": [
{
"reference": "http://www.ALKholood.com/Task/583924"
}
]
}
},
{
"fullUrl": "http://www.ALKholood.com/Task/583924",
"resource": {
"resourceType": "Task",
"id": "583924",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/task|1.0.0"
]
},
"identifier": [
{
"use": "official",
"system": "http://www.ALKholood.com/Task",
"value": "PlReq_920261024154845"
}
],
"status": "requested",
"intent": "order",
"priority": "stat",
"code": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-code",
"code": "poll"
}
]
},
"authoredOn": "2026-09-24",
"lastModified": "2026-10-24",
"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": "2026-09-24T00:00:00.000\u002B03:00",
"end": "2026-10-24T23:59:59.999\u002B03:00"
}
},
{
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-input-type",
"code": "count"
}
]
},
"valuePositiveInt": 10
}
]
}
},
{
"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"
}
}
]
}
The middleware wrapper exactly as posted. MessageBody is elided
because it is only base64 of the FHIR bundle on the Request tab.
{
"Credentials": {
"user": "TEMP-NNIC-PROV",
"password": "TEMP-NNIC-PROV",
"providerno": "10000300062591"
},
"MessageBody": "\u003Cbase64 of the FHIR bundle omitted \u2014 3840 chars\u003E",
"BundleID": "bc5fc905-ac4c-45f2-bea5-e578a8623449"
}
{
"resourceType": "Bundle",
"id": "54a42b83-435e-4caa-99b4-56ed1b324165",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-24T15:48:43.683\u002B03:00",
"entry": [
{
"fullUrl": "http://nphies.sa/MessageHeader/65d3c9dc-d823-412c-9d50-b20adeab3afa",
"resource": {
"resourceType": "MessageHeader",
"id": "65d3c9dc-d823-412c-9d50-b20adeab3afa",
"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": "7b4507a5-dbb0-4f27-ac1e-2f31da31b36a",
"code": "ok"
}
}
},
{
"fullUrl": "http://nphies.sa/Task/21a188bd-15c3-4180-9167-7b738c9adc0e",
"resource": {
"resourceType": "Task",
"id": "21a188bd-15c3-4180-9167-7b738c9adc0e",
"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": "317"
}
],
"status": "completed",
"intent": "order",
"priority": "stat",
"code": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-code",
"code": "poll"
}
]
},
"authoredOn": "2026-09-24",
"lastModified": "2026-10-24",
"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": "2026-09-24T00:00:00.000\u002B03:00",
"end": "2026-10-24T23:59:59.999\u002B03:00"
}
},
{
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-input-type",
"code": "count"
}
]
},
"valuePositiveInt": 10
}
],
"output": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:37.926\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/fe2971ad-b0c7-4c2b-bb9e-3ca0febd871b"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:37.966\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/cba3352b-a42f-4e3b-b32f-4a7fc931ad43"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:38.000\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/c8a064e1-c554-41c5-b802-ea8814a53495"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:38.050\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/0281ea1e-a93c-47f8-b2da-a22ca836805a"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:38.094\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/b01614d8-a29e-47b5-a120-360bc560dd42"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:38.116\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/5ad3d230-08e0-4e13-a3b4-6af257b4d3e9"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:38.127\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/a5c0b7e0-94c1-487a-826e-7c3c7d387bd1"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:38.192\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/f378c602-8144-4eb0-9038-84e9ebfa274a"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:38.270\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/0fd63855-e9ab-4a34-b39e-218a20f67905"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:42:38.326\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/1ddbdc39-93fc-4895-94b7-b0d87f27feaf"
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/fe2971ad-b0c7-4c2b-bb9e-3ca0febd871b",
"resource": {
"resourceType": "Bundle",
"id": "fe2971ad-b0c7-4c2b-bb9e-3ca0febd871b",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.465\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/4e20107b-39e7-42fd-968e-78f3c3ba9216",
"resource": {
"resourceType": "MessageHeader",
"id": "4e20107b-39e7-42fd-968e-78f3c3ba9216",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "3f6f0f98-343e-4bc1-ae96-105ea96f08f1",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/1be36616-8a5f-4cc3-ba68-45b0afe29493"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/1be36616-8a5f-4cc3-ba68-45b0afe29493",
"resource": {
"resourceType": "ClaimResponse",
"id": "1be36616-8a5f-4cc3-ba68-45b0afe29493",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "2261"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "1be36616-8a5f-4cc3-ba68-45b0afe29493"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/b9a5fa9b-4124-481c-a61e-38f2c3b5c403"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/2cabe1d6-aa30-4dda-bbe0-eec80b24424f"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/d5dfecb7-e924-46f9-9941-09a4151808e0"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "39182134260926"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "99303"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "99303"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"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://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"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": "submitted"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 75.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 54,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 13.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 75.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 8.1,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/19281c3a-7019-411f-9929-00ae2da58351"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/b9a5fa9b-4124-481c-a61e-38f2c3b5c403",
"resource": {
"resourceType": "Patient",
"id": "b9a5fa9b-4124-481c-a61e-38f2c3b5c403",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "NI",
"display": "National ID"
}
]
},
"system": "http://nphies.sa/identifier/nationalid",
"value": "1021164023"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "JAMILAAH ABDULAZIZ ahmed alahmady",
"given": [
"JAMILAAH",
"ahmed",
"alahmady"
]
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "1967-10-04",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/d5dfecb7-e924-46f9-9941-09a4151808e0",
"resource": {
"resourceType": "Organization",
"id": "d5dfecb7-e924-46f9-9941-09a4151808e0",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/2cabe1d6-aa30-4dda-bbe0-eec80b24424f",
"resource": {
"resourceType": "Organization",
"id": "2cabe1d6-aa30-4dda-bbe0-eec80b24424f",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/19281c3a-7019-411f-9929-00ae2da58351",
"resource": {
"resourceType": "Coverage",
"id": "19281c3a-7019-411f-9929-00ae2da58351",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "001098706359511"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/6dabccda-3402-43ef-9182-403317e50035"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/1ae47fd4-b602-4733-ad11-c2018372aa7a"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/b9a5fa9b-4124-481c-a61e-38f2c3b5c403"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/2cabe1d6-aa30-4dda-bbe0-eec80b24424f"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "3511",
"name": "MINISTRY OF FOREIGN AFFAIRS"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/6dabccda-3402-43ef-9182-403317e50035",
"resource": {
"resourceType": "Organization",
"id": "6dabccda-3402-43ef-9182-403317e50035",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/1ae47fd4-b602-4733-ad11-c2018372aa7a",
"resource": {
"resourceType": "Patient",
"id": "1ae47fd4-b602-4733-ad11-c2018372aa7a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "NI",
"display": "National ID"
}
]
},
"system": "http://nphies.sa/identifier/nationalid",
"value": "1021164023"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "JAMILAAH ABDULAZIZ ahmed alahmady",
"given": [
"JAMILAAH",
"ahmed",
"alahmady"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0500610051"
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "1967-10-04",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/cba3352b-a42f-4e3b-b32f-4a7fc931ad43",
"resource": {
"resourceType": "Bundle",
"id": "cba3352b-a42f-4e3b-b32f-4a7fc931ad43",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.330\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/2c6a3104-e2ba-4f6e-8f4a-660679b1dd38",
"resource": {
"resourceType": "MessageHeader",
"id": "2c6a3104-e2ba-4f6e-8f4a-660679b1dd38",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "7ef78f52-90f9-43f0-829f-d883b41dbd79",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/5ec4663c-4f66-467b-b38f-c7dfb7a8b96d"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/5ec4663c-4f66-467b-b38f-c7dfb7a8b96d",
"resource": {
"resourceType": "ClaimResponse",
"id": "5ec4663c-4f66-467b-b38f-c7dfb7a8b96d",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "partial"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "1672"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "5ec4663c-4f66-467b-b38f-c7dfb7a8b96d"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/4ba5b0bc-bd21-4b3d-9746-c9c6430e7cb9"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/3627b244-7006-48e5-b484-1c13f5c3d973"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/a03382b7-e0e0-4057-8c85-9203377d878c"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "85166396260920"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "93220"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 17.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 2.64,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 24.64,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 4.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 24.64,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "93220"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 11,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 1.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 15.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 15.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 2.75,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "93220"
}
}
],
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "93220"
}
}
],
"itemSequence": 4,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 32,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8,
"currency": "SAR"
}
},
{
"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": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "93220"
}
}
],
"itemSequence": 5,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "93220"
}
}
],
"itemSequence": 6,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 35.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 5.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "93220"
}
}
],
"itemSequence": 7,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "93220"
}
}
],
"itemSequence": 8,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"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": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 257.32,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 161.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 45.95,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 257.32,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 24.27,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/11135fbe-ece7-49f7-9231-a991391c0a3a"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/4ba5b0bc-bd21-4b3d-9746-c9c6430e7cb9",
"resource": {
"resourceType": "Patient",
"id": "4ba5b0bc-bd21-4b3d-9746-c9c6430e7cb9",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2053216590"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "FATMAH QASSEM YOUSSEF ALAHDAL",
"given": [
"FATMAH",
"YOUSSEF",
"ALAHDAL"
]
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "1987-08-25",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/a03382b7-e0e0-4057-8c85-9203377d878c",
"resource": {
"resourceType": "Organization",
"id": "a03382b7-e0e0-4057-8c85-9203377d878c",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/3627b244-7006-48e5-b484-1c13f5c3d973",
"resource": {
"resourceType": "Organization",
"id": "3627b244-7006-48e5-b484-1c13f5c3d973",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/11135fbe-ece7-49f7-9231-a991391c0a3a",
"resource": {
"resourceType": "Coverage",
"id": "11135fbe-ece7-49f7-9231-a991391c0a3a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002270585603101"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/d959ba45-5016-4090-aff4-e57dfbaf8053"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/15ac85eb-c71b-40dd-8c26-ef785e8a1f21"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/4ba5b0bc-bd21-4b3d-9746-c9c6430e7cb9"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/3627b244-7006-48e5-b484-1c13f5c3d973"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "48655111",
"name": "FAWAHHA ALKHALIJ COM Basic B"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/d959ba45-5016-4090-aff4-e57dfbaf8053",
"resource": {
"resourceType": "Organization",
"id": "d959ba45-5016-4090-aff4-e57dfbaf8053",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/15ac85eb-c71b-40dd-8c26-ef785e8a1f21",
"resource": {
"resourceType": "Patient",
"id": "15ac85eb-c71b-40dd-8c26-ef785e8a1f21",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2053216590"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "FATMAH QASSEM YOUSSEF ALAHDAL",
"given": [
"FATMAH",
"YOUSSEF",
"ALAHDAL"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0550331510"
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "1987-08-25",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/c8a064e1-c554-41c5-b802-ea8814a53495",
"resource": {
"resourceType": "Bundle",
"id": "c8a064e1-c554-41c5-b802-ea8814a53495",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.691\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/4142f878-7b4a-4889-a9b3-9f3a5281c02a",
"resource": {
"resourceType": "MessageHeader",
"id": "4142f878-7b4a-4889-a9b3-9f3a5281c02a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "3a7c8acc-ba61-47f6-98c7-cdba320ba8fb",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/f0af1fc0-b831-4fc2-ba19-a32d4a525e18"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/f0af1fc0-b831-4fc2-ba19-a32d4a525e18",
"resource": {
"resourceType": "ClaimResponse",
"id": "f0af1fc0-b831-4fc2-ba19-a32d4a525e18",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "1091"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "f0af1fc0-b831-4fc2-ba19-a32d4a525e18"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/b74f1b6d-42af-4c6e-8c37-3c3a900fc6f8"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/4deab426-6642-4b97-9438-b791d381eb76"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/5e5a72b8-7032-49df-9eda-936d50d76708"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "19149774260913"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "86768"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 20,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 20,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/f3eb630f-cadd-4088-8f90-cf3160791afd"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/b74f1b6d-42af-4c6e-8c37-3c3a900fc6f8",
"resource": {
"resourceType": "Patient",
"id": "b74f1b6d-42af-4c6e-8c37-3c3a900fc6f8",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2300974686"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "AALA mehmood abdulhameed",
"given": [
"AALA",
"mehmood",
"abdulhameed"
]
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "2010-12-19",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/5e5a72b8-7032-49df-9eda-936d50d76708",
"resource": {
"resourceType": "Organization",
"id": "5e5a72b8-7032-49df-9eda-936d50d76708",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/4deab426-6642-4b97-9438-b791d381eb76",
"resource": {
"resourceType": "Organization",
"id": "4deab426-6642-4b97-9438-b791d381eb76",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/f3eb630f-cadd-4088-8f90-cf3160791afd",
"resource": {
"resourceType": "Coverage",
"id": "f3eb630f-cadd-4088-8f90-cf3160791afd",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002255372050201"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/096356e6-a6a9-45ed-952b-5b86d4aa36a1"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/b1f03226-0639-46bd-91ed-3446e29278e8"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/b74f1b6d-42af-4c6e-8c37-3c3a900fc6f8"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/4deab426-6642-4b97-9438-b791d381eb76"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "56078458",
"name": "ABDULLAH HASHIM COMPANY LTD"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/096356e6-a6a9-45ed-952b-5b86d4aa36a1",
"resource": {
"resourceType": "Organization",
"id": "096356e6-a6a9-45ed-952b-5b86d4aa36a1",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/b1f03226-0639-46bd-91ed-3446e29278e8",
"resource": {
"resourceType": "Patient",
"id": "b1f03226-0639-46bd-91ed-3446e29278e8",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2300974686"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "AALA mehmood abdulhameed",
"given": [
"AALA",
"mehmood",
"abdulhameed"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0566647625"
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "2010-12-19",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/0281ea1e-a93c-47f8-b2da-a22ca836805a",
"resource": {
"resourceType": "Bundle",
"id": "0281ea1e-a93c-47f8-b2da-a22ca836805a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.337\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/0d9548de-379a-4eef-9354-e0338355f945",
"resource": {
"resourceType": "MessageHeader",
"id": "0d9548de-379a-4eef-9354-e0338355f945",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "6182463d-3aca-4afd-94fb-840d96fc325b",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/8d7d605e-0b6d-4a4c-943a-0673ec1a5f3d"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/8d7d605e-0b6d-4a4c-943a-0673ec1a5f3d",
"resource": {
"resourceType": "ClaimResponse",
"id": "8d7d605e-0b6d-4a4c-943a-0673ec1a5f3d",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "partial"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "1483"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "8d7d605e-0b6d-4a4c-943a-0673ec1a5f3d"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/338cd136-946e-4f75-9117-95b76ede6aeb"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/a6fcf2bf-0803-4b6e-95aa-d468f3ceb002"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/bed89a7d-2f1c-49bf-bb96-becd05eea993"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "9160997260917"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "90980"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "MN-1-1"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 61.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 11,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 61.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "90980"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "AD-1-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "90980"
}
}
],
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "90980"
}
}
],
"itemSequence": 4,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 20,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "90980"
}
}
],
"itemSequence": 5,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "90980"
}
}
],
"itemSequence": 6,
"adjudication": [
{
"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": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 61.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 11,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 61.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 44,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "90980"
}
}
],
"itemSequence": 7,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "AD-1-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 292.88,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 108,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 52.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 292.88,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 16.2,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/64bb32c9-6ae0-41db-94c5-4c206c507455"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/338cd136-946e-4f75-9117-95b76ede6aeb",
"resource": {
"resourceType": "Patient",
"id": "338cd136-946e-4f75-9117-95b76ede6aeb",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2305818326"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "YASSER SAMIR MOHAMAD MOHAMAD",
"given": [
"YASSER",
"MOHAMAD",
"MOHAMAD"
]
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "1987-06-04",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/bed89a7d-2f1c-49bf-bb96-becd05eea993",
"resource": {
"resourceType": "Organization",
"id": "bed89a7d-2f1c-49bf-bb96-becd05eea993",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/a6fcf2bf-0803-4b6e-95aa-d468f3ceb002",
"resource": {
"resourceType": "Organization",
"id": "a6fcf2bf-0803-4b6e-95aa-d468f3ceb002",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/64bb32c9-6ae0-41db-94c5-4c206c507455",
"resource": {
"resourceType": "Coverage",
"id": "64bb32c9-6ae0-41db-94c5-4c206c507455",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002305818326001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/5f481982-9387-4297-855f-6ea6c6419826"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/90ed7630-84ad-468a-9682-9222f69f1938"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/338cd136-946e-4f75-9117-95b76ede6aeb"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/a6fcf2bf-0803-4b6e-95aa-d468f3ceb002"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "54157468",
"name": "IBLEC COMPANY"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/5f481982-9387-4297-855f-6ea6c6419826",
"resource": {
"resourceType": "Organization",
"id": "5f481982-9387-4297-855f-6ea6c6419826",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/90ed7630-84ad-468a-9682-9222f69f1938",
"resource": {
"resourceType": "Patient",
"id": "90ed7630-84ad-468a-9682-9222f69f1938",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2305818326"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "YASSER SAMIR MOHAMAD MOHAMAD",
"given": [
"YASSER",
"MOHAMAD",
"MOHAMAD"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0549409175"
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "1987-06-04",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/b01614d8-a29e-47b5-a120-360bc560dd42",
"resource": {
"resourceType": "Bundle",
"id": "b01614d8-a29e-47b5-a120-360bc560dd42",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.262\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/4b801010-ec11-4a7c-a502-a45743494b8c",
"resource": {
"resourceType": "MessageHeader",
"id": "4b801010-ec11-4a7c-a502-a45743494b8c",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "8fb7579d-373c-4e8e-a820-bf96691d45ea",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/756e21fd-4fcf-4dfc-962e-acdae6172d8e"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/756e21fd-4fcf-4dfc-962e-acdae6172d8e",
"resource": {
"resourceType": "ClaimResponse",
"id": "756e21fd-4fcf-4dfc-962e-acdae6172d8e",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "partial"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "2582"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "756e21fd-4fcf-4dfc-962e-acdae6172d8e"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/358ef0ed-1eec-4d5f-bcbf-9ae624f60fa9"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/2dd20c13-04bf-45af-befb-b89b2ad3c46d"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/18e989e9-d6bc-425d-9be5-579d9b85eb27"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "46191992260929"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "102571"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 74.35,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 11.15,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 93.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.15,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 93.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "102571"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 110,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 16.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 156.08,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 156.08,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 13.58,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "102571"
}
}
],
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 93.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 74.35,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.15,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 11.15,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 93.65,
"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": 3
}
]
},
{
"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": "102571"
}
}
],
"itemSequence": 4,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 18.48,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 18.48,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://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": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "102571"
}
}
],
"itemSequence": 5,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 124.87,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 124.87,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 97.7,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 10.86,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 14.66,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "102571"
}
}
],
"itemSequence": 6,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 74.35,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 93.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 11.15,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 93.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.15,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 3
}
]
},
{
"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": "102571"
}
}
],
"itemSequence": 7,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 21.12,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 199.79,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 17.38,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 199.79,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 140.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "102571"
}
}
],
"itemSequence": 8,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 62.43,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.43,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 62.43,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 49.57,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 7.44,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 842.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 621.12,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 75,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 842.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 93.17,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/5deb83ca-95ae-4bca-af9f-e660f4bb354e"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/358ef0ed-1eec-4d5f-bcbf-9ae624f60fa9",
"resource": {
"resourceType": "Patient",
"id": "358ef0ed-1eec-4d5f-bcbf-9ae624f60fa9",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2629084522"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "HMADA ALI ahmed",
"given": [
"HMADA",
"ALI",
"ahmed"
]
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "2001-06-07",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/18e989e9-d6bc-425d-9be5-579d9b85eb27",
"resource": {
"resourceType": "Organization",
"id": "18e989e9-d6bc-425d-9be5-579d9b85eb27",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/2dd20c13-04bf-45af-befb-b89b2ad3c46d",
"resource": {
"resourceType": "Organization",
"id": "2dd20c13-04bf-45af-befb-b89b2ad3c46d",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/5deb83ca-95ae-4bca-af9f-e660f4bb354e",
"resource": {
"resourceType": "Coverage",
"id": "5deb83ca-95ae-4bca-af9f-e660f4bb354e",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002629084522001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/8ba54513-3e1a-4955-83be-bcae7f2d22d9"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/75f18a22-e06c-4edd-a8b9-80321aeac1ee"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/358ef0ed-1eec-4d5f-bcbf-9ae624f60fa9"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/2dd20c13-04bf-45af-befb-b89b2ad3c46d"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "50301312",
"name": "Almedyafi Co"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/8ba54513-3e1a-4955-83be-bcae7f2d22d9",
"resource": {
"resourceType": "Organization",
"id": "8ba54513-3e1a-4955-83be-bcae7f2d22d9",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/75f18a22-e06c-4edd-a8b9-80321aeac1ee",
"resource": {
"resourceType": "Patient",
"id": "75f18a22-e06c-4edd-a8b9-80321aeac1ee",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2629084522"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "HMADA ALI ahmed",
"given": [
"HMADA",
"ALI",
"ahmed"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0549640932"
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "2001-06-07",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/5ad3d230-08e0-4e13-a3b4-6af257b4d3e9",
"resource": {
"resourceType": "Bundle",
"id": "5ad3d230-08e0-4e13-a3b4-6af257b4d3e9",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.355\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/60b9a3b8-0140-4463-a404-3b53c3a1e15e",
"resource": {
"resourceType": "MessageHeader",
"id": "60b9a3b8-0140-4463-a404-3b53c3a1e15e",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "0311b398-a3a6-4ba4-94c9-9dc9bd30e804",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/25db4a91-3af3-449c-8874-0b96b319946a"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/25db4a91-3af3-449c-8874-0b96b319946a",
"resource": {
"resourceType": "ClaimResponse",
"id": "25db4a91-3af3-449c-8874-0b96b319946a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "852"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "25db4a91-3af3-449c-8874-0b96b319946a"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/76501aac-f987-4137-930d-14d969c27b7e"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/02bde4a5-8bd8-4bf7-a7d1-60367911e78c"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/1d685949-bd5e-4826-b388-2bd953ccffc0"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "89143197260910"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "84084"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 20,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "84084"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"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": "deductible"
}
]
},
"amount": {
"value": 0,
"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": "submitted"
}
]
},
"amount": {
"value": 61.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 61.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 89.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 64,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 16,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 89.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 9.6,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/8dd0d0a6-447f-411c-8551-65d8c60958fe"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/76501aac-f987-4137-930d-14d969c27b7e",
"resource": {
"resourceType": "Patient",
"id": "76501aac-f987-4137-930d-14d969c27b7e",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2184289201"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "Abdullah BNFJH abkr",
"given": [
"Abdullah",
"BNFJH",
"abkr"
]
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "1979-01-01",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/1d685949-bd5e-4826-b388-2bd953ccffc0",
"resource": {
"resourceType": "Organization",
"id": "1d685949-bd5e-4826-b388-2bd953ccffc0",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/02bde4a5-8bd8-4bf7-a7d1-60367911e78c",
"resource": {
"resourceType": "Organization",
"id": "02bde4a5-8bd8-4bf7-a7d1-60367911e78c",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/8dd0d0a6-447f-411c-8551-65d8c60958fe",
"resource": {
"resourceType": "Coverage",
"id": "8dd0d0a6-447f-411c-8551-65d8c60958fe",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002184289201001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/2bedf5cc-cc3b-4a5d-9396-38f08a762515"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/a97a0847-7d41-4834-883f-f3a3f7dbdcd9"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/76501aac-f987-4137-930d-14d969c27b7e"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/02bde4a5-8bd8-4bf7-a7d1-60367911e78c"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "52244576",
"name": "DIGITAL SOLUTIONS PROVIDER CO"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/2bedf5cc-cc3b-4a5d-9396-38f08a762515",
"resource": {
"resourceType": "Organization",
"id": "2bedf5cc-cc3b-4a5d-9396-38f08a762515",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/a97a0847-7d41-4834-883f-f3a3f7dbdcd9",
"resource": {
"resourceType": "Patient",
"id": "a97a0847-7d41-4834-883f-f3a3f7dbdcd9",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2184289201"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "Abdullah BNFJH abkr",
"given": [
"Abdullah",
"BNFJH",
"abkr"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0556722320"
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "1979-01-01",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/a5c0b7e0-94c1-487a-826e-7c3c7d387bd1",
"resource": {
"resourceType": "Bundle",
"id": "a5c0b7e0-94c1-487a-826e-7c3c7d387bd1",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.333\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/7d66b0df-db55-400a-86fd-64baf1caa9ab",
"resource": {
"resourceType": "MessageHeader",
"id": "7d66b0df-db55-400a-86fd-64baf1caa9ab",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "d426417d-4164-4b93-93a7-cf922d204800",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/a3a6fcf9-fb11-438b-a6d1-73bf7cd45485"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/a3a6fcf9-fb11-438b-a6d1-73bf7cd45485",
"resource": {
"resourceType": "ClaimResponse",
"id": "a3a6fcf9-fb11-438b-a6d1-73bf7cd45485",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "partial"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "2289"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "a3a6fcf9-fb11-438b-a6d1-73bf7cd45485"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/93da074f-0282-4d6e-9f23-3cc0d08da767"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/025eef49-5ce0-4ecd-bf93-ee018376151b"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/d1b537dd-84ab-4d13-ac62-a5a03408f987"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "20182773260927"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "99537"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 20,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "99537"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "AD-1-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.25,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 46.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 46.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 74.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 20,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 13.25,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 74.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/1a60af5c-2096-43c8-a0e8-f2cf1aca7b7c"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/93da074f-0282-4d6e-9f23-3cc0d08da767",
"resource": {
"resourceType": "Patient",
"id": "93da074f-0282-4d6e-9f23-3cc0d08da767",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "NI",
"display": "National ID"
}
]
},
"system": "http://nphies.sa/identifier/nationalid",
"value": "1137136352"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "Haya ahmed Essairy",
"given": [
"Haya",
"ahmed",
"Essairy"
]
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "2006-10-07",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/d1b537dd-84ab-4d13-ac62-a5a03408f987",
"resource": {
"resourceType": "Organization",
"id": "d1b537dd-84ab-4d13-ac62-a5a03408f987",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/025eef49-5ce0-4ecd-bf93-ee018376151b",
"resource": {
"resourceType": "Organization",
"id": "025eef49-5ce0-4ecd-bf93-ee018376151b",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/1a60af5c-2096-43c8-a0e8-f2cf1aca7b7c",
"resource": {
"resourceType": "Coverage",
"id": "1a60af5c-2096-43c8-a0e8-f2cf1aca7b7c",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "001137136352001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/49ffd3eb-93e0-4767-9cb5-a84355b64370"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/8a82a626-f980-4312-b64e-c061157d9834"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/93da074f-0282-4d6e-9f23-3cc0d08da767"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/025eef49-5ce0-4ecd-bf93-ee018376151b"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "58805007",
"name": "NAMA ARABIA TRADING CO"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/49ffd3eb-93e0-4767-9cb5-a84355b64370",
"resource": {
"resourceType": "Organization",
"id": "49ffd3eb-93e0-4767-9cb5-a84355b64370",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/8a82a626-f980-4312-b64e-c061157d9834",
"resource": {
"resourceType": "Patient",
"id": "8a82a626-f980-4312-b64e-c061157d9834",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "NI",
"display": "National ID"
}
]
},
"system": "http://nphies.sa/identifier/nationalid",
"value": "1137136352"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "Haya ahmed Essairy",
"given": [
"Haya",
"ahmed",
"Essairy"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0535045958"
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "2006-10-07",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/f378c602-8144-4eb0-9038-84e9ebfa274a",
"resource": {
"resourceType": "Bundle",
"id": "f378c602-8144-4eb0-9038-84e9ebfa274a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.259\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/4b8a8f28-6eac-4241-b0ce-fecfb3587cc6",
"resource": {
"resourceType": "MessageHeader",
"id": "4b8a8f28-6eac-4241-b0ce-fecfb3587cc6",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "6d4c0be7-cb25-4d44-b725-8cef40095529",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/804bedb0-b5f2-42e2-a379-f16b3a0bbb70"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/804bedb0-b5f2-42e2-a379-f16b3a0bbb70",
"resource": {
"resourceType": "ClaimResponse",
"id": "804bedb0-b5f2-42e2-a379-f16b3a0bbb70",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "672"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "804bedb0-b5f2-42e2-a379-f16b3a0bbb70"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/f93f3447-b0a5-4955-946d-b1f468f9d05b"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/20a93ac5-73e8-4f9c-853a-18b5c33ef9e2"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/a08101d7-0c19-4ff0-b951-cf04c5c0689a"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "95138092260908"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "82052"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 32,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 4.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 32,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 4.8,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/8392d9fe-2d60-4e49-8206-f424d3cf35d7"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/f93f3447-b0a5-4955-946d-b1f468f9d05b",
"resource": {
"resourceType": "Patient",
"id": "f93f3447-b0a5-4955-946d-b1f468f9d05b",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2065722064"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "MOHAMMED AHMED ALI AHRHRH",
"given": [
"MOHAMMED",
"ALI",
"AHRHRH"
]
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "1990-07-23",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/a08101d7-0c19-4ff0-b951-cf04c5c0689a",
"resource": {
"resourceType": "Organization",
"id": "a08101d7-0c19-4ff0-b951-cf04c5c0689a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/20a93ac5-73e8-4f9c-853a-18b5c33ef9e2",
"resource": {
"resourceType": "Organization",
"id": "20a93ac5-73e8-4f9c-853a-18b5c33ef9e2",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/8392d9fe-2d60-4e49-8206-f424d3cf35d7",
"resource": {
"resourceType": "Coverage",
"id": "8392d9fe-2d60-4e49-8206-f424d3cf35d7",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002065722064001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/e7007ea1-599a-4ff4-9c34-25ccb8a12c5d"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/2383722c-4d44-4b51-b880-5af9e3412cc1"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/f93f3447-b0a5-4955-946d-b1f468f9d05b"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/20a93ac5-73e8-4f9c-853a-18b5c33ef9e2"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "55531294",
"name": "Kingdom Lighting Tra Basic B"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/e7007ea1-599a-4ff4-9c34-25ccb8a12c5d",
"resource": {
"resourceType": "Organization",
"id": "e7007ea1-599a-4ff4-9c34-25ccb8a12c5d",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/2383722c-4d44-4b51-b880-5af9e3412cc1",
"resource": {
"resourceType": "Patient",
"id": "2383722c-4d44-4b51-b880-5af9e3412cc1",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PRC",
"display": "iqama"
}
]
},
"system": "http://nphies.sa/identifier/iqama",
"value": "2065722064"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "MOHAMMED AHMED ALI AHRHRH",
"given": [
"MOHAMMED",
"ALI",
"AHRHRH"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0531630751"
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "1990-07-23",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/0fd63855-e9ab-4a34-b39e-218a20f67905",
"resource": {
"resourceType": "Bundle",
"id": "0fd63855-e9ab-4a34-b39e-218a20f67905",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.826\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/88cc4ae4-0cad-4c6d-96e4-9cff743956e0",
"resource": {
"resourceType": "MessageHeader",
"id": "88cc4ae4-0cad-4c6d-96e4-9cff743956e0",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "3a0bd328-93e5-45e0-9298-4e218572e5f4",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/84a687e7-95c4-4b0a-b782-a1cb681c2354"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/84a687e7-95c4-4b0a-b782-a1cb681c2354",
"resource": {
"resourceType": "ClaimResponse",
"id": "84a687e7-95c4-4b0a-b782-a1cb681c2354",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "partial"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "2380"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "84a687e7-95c4-4b0a-b782-a1cb681c2354"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/f6a78bcf-38be-48e4-945e-17da062e7bbb"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/5c4a5a09-260e-47a7-b857-84f954593efc"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/3c108a34-8752-42e5-871c-e91e8912e53f"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "51185580260927"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100427"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 36.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 36.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "AD-1-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 6.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100427"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 6.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 36.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 36.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "AD-1-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100427"
}
}
],
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "AD-1-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://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": 0
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100427"
}
}
],
"itemSequence": 4,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 154,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 27.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 154,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 110,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 16.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100427"
}
}
],
"itemSequence": 5,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 20,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 305.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 130,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 54.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 305.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 19.5,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/8f1e369b-7630-4f9c-b841-e669be38281c"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/f6a78bcf-38be-48e4-945e-17da062e7bbb",
"resource": {
"resourceType": "Patient",
"id": "f6a78bcf-38be-48e4-945e-17da062e7bbb",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "NI",
"display": "National ID"
}
]
},
"system": "http://nphies.sa/identifier/nationalid",
"value": "1119849956"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "AGWAA talal TAYAB TAYAB",
"given": [
"AGWAA",
"TAYAB",
"TAYAB"
]
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "2001-11-23",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/3c108a34-8752-42e5-871c-e91e8912e53f",
"resource": {
"resourceType": "Organization",
"id": "3c108a34-8752-42e5-871c-e91e8912e53f",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/5c4a5a09-260e-47a7-b857-84f954593efc",
"resource": {
"resourceType": "Organization",
"id": "5c4a5a09-260e-47a7-b857-84f954593efc",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/8f1e369b-7630-4f9c-b841-e669be38281c",
"resource": {
"resourceType": "Coverage",
"id": "8f1e369b-7630-4f9c-b841-e669be38281c",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "001119849956001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/8ef2ba72-945a-477b-a8ba-e44b25156073"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/3d744d95-8349-49f9-9aab-6f3f50f9b860"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/f6a78bcf-38be-48e4-945e-17da062e7bbb"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/5c4a5a09-260e-47a7-b857-84f954593efc"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "53714773",
"name": "ANDALUS ALYOSR EDUCATIONAL COMPANY"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/8ef2ba72-945a-477b-a8ba-e44b25156073",
"resource": {
"resourceType": "Organization",
"id": "8ef2ba72-945a-477b-a8ba-e44b25156073",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/3d744d95-8349-49f9-9aab-6f3f50f9b860",
"resource": {
"resourceType": "Patient",
"id": "3d744d95-8349-49f9-9aab-6f3f50f9b860",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "NI",
"display": "National ID"
}
]
},
"system": "http://nphies.sa/identifier/nationalid",
"value": "1119849956"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "AGWAA talal TAYAB TAYAB",
"given": [
"AGWAA",
"TAYAB",
"TAYAB"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0566766595"
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "2001-11-23",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/1ddbdc39-93fc-4895-94b7-b0d87f27feaf",
"resource": {
"resourceType": "Bundle",
"id": "1ddbdc39-93fc-4895-94b7-b0d87f27feaf",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:42:37.272\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/1f3a81c5-a11f-4fd1-8e88-b5deae80dd86",
"resource": {
"resourceType": "MessageHeader",
"id": "1f3a81c5-a11f-4fd1-8e88-b5deae80dd86",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/message-header|1.0.0"
]
},
"eventCoding": {
"system": "http://nphies.sa/terminology/CodeSystem/ksa-message-events",
"code": "claim-response"
},
"destination": [
{
"endpoint": "http://www.ALKholood.com",
"receiver": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
}
}
],
"sender": {
"type": "Organization",
"identifier": {
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
},
"source": {
"endpoint": "https://tawuniya.com.sa"
},
"response": {
"identifier": "9818ce5b-a757-4f1e-acfd-38b64ece4889",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/389248f7-5678-4a65-9e05-ca063bce2ae9"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/389248f7-5678-4a65-9e05-ca063bce2ae9",
"resource": {
"resourceType": "ClaimResponse",
"id": "389248f7-5678-4a65-9e05-ca063bce2ae9",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/prior-auth-response|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "partial"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/reissue-reason",
"code": "adjudication"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier",
"valueIdentifier": {
"system": "http://www.ALKholood.com/episode",
"value": "2354"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "389248f7-5678-4a65-9e05-ca063bce2ae9"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/540a4e54-446d-4909-83ee-815f2a2eaee3"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/5b183fac-a66c-4f6b-aaad-b5006eb2e000"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/07342aab-ec50-4b23-8c97-88940afd727b"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "39184657260927"
}
},
"outcome": "complete",
"disposition": "-",
"item": [
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100138"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 26.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 36.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 6.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 36.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100138"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 35.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 5.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100138"
}
}
],
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"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": "tax"
}
]
},
"amount": {
"value": 4.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 44.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100138"
}
}
],
"itemSequence": 4,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 15.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 15.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 11,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 2.75,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 1.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100138"
}
}
],
"itemSequence": 5,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100138"
}
}
],
"itemSequence": 6,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100138"
}
}
],
"itemSequence": 7,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 3.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.5,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 30.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "rejected"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100138"
}
}
],
"itemSequence": 8,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.8,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 49.28,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "AD-1-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 288.12,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 170.6,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 51.45,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 288.12,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 25.59,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/f3871217-b837-4fe0-9b05-a812448c041a"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/540a4e54-446d-4909-83ee-815f2a2eaee3",
"resource": {
"resourceType": "Patient",
"id": "540a4e54-446d-4909-83ee-815f2a2eaee3",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "NI",
"display": "National ID"
}
]
},
"system": "http://nphies.sa/identifier/nationalid",
"value": "1169824040"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "KALID MAZEN KHESHAN ALMAWLID",
"given": [
"KALID",
"KHESHAN",
"ALMAWLID"
]
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "2014-07-19",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/07342aab-ec50-4b23-8c97-88940afd727b",
"resource": {
"resourceType": "Organization",
"id": "07342aab-ec50-4b23-8c97-88940afd727b",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/5b183fac-a66c-4f6b-aaad-b5006eb2e000",
"resource": {
"resourceType": "Organization",
"id": "5b183fac-a66c-4f6b-aaad-b5006eb2e000",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization|1.0.0"
]
},
"identifier": [
{
"system": "http://nphies.sa/license/payer-license",
"value": "7000911508"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "ins"
}
]
}
],
"name": "The Cooperative Company for Cooperative Insurance"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Coverage/f3871217-b837-4fe0-9b05-a812448c041a",
"resource": {
"resourceType": "Coverage",
"id": "f3871217-b837-4fe0-9b05-a812448c041a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "001013651698201"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/86d0763c-5983-4f24-8fca-db7a6bb2f9cf"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/ebd84646-90c9-43bb-b91a-c5a88f08e1f6"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/540a4e54-446d-4909-83ee-815f2a2eaee3"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/5b183fac-a66c-4f6b-aaad-b5006eb2e000"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "49441366",
"name": "High Flavor Trading Basic B"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/86d0763c-5983-4f24-8fca-db7a6bb2f9cf",
"resource": {
"resourceType": "Organization",
"id": "86d0763c-5983-4f24-8fca-db7a6bb2f9cf",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/policyholder-organization|1.0.0"
]
},
"active": true,
"name": "Policy Holder"
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/ebd84646-90c9-43bb-b91a-c5a88f08e1f6",
"resource": {
"resourceType": "Patient",
"id": "ebd84646-90c9-43bb-b91a-c5a88f08e1f6",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient|1.0.0"
]
},
"extension": [
{
"url": "https://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-nationality",
"valueCodeableConcept": {
"coding": [
{
"system": "https://nphies.sa/terminology/CodeSystem/nationality",
"code": "PAK"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patient-religion",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/religion",
"code": "0",
"display": "other"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-occupation",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/occupation",
"code": "others",
"display": "others"
}
]
}
}
],
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "NI",
"display": "National ID"
}
]
},
"system": "http://nphies.sa/identifier/nationalid",
"value": "1169824040"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "KALID MAZEN KHESHAN ALMAWLID",
"given": [
"KALID",
"KHESHAN",
"ALMAWLID"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0508031875"
}
],
"gender": "male",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "male",
"display": "male"
}
]
}
}
]
},
"birthDate": "2014-07-19",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://www.ALKholood.com/Organization/9",
"resource": {
"resourceType": "Organization",
"id": "9",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization|1.0.0"
]
},
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-provider-type",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/provider-type",
"code": "5",
"display": "Clinic"
}
]
}
}
],
"identifier": [
{
"use": "official",
"system": "http://nphies.sa/license/provider-license",
"value": "10000300062591"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/organization-type",
"code": "prov"
}
]
}
],
"name": "Al-Kholood Medical Company - AlHaj"
}
}
]
}
No stored-procedure executions recorded
Either the poll failed before reaching the database, or SQL capture
is switched off in the Diagnostics configuration section.