Error Al-Kholood Medical Company - AlHaj claim-response
All traces- Trace
- d9710ba8-7393-48d8-a699-1e5e82b6476b
- Started
- 2026-10-30 21:17:56.140 +03:00
- Branch
- Al-Kholood Medical Company - AlHaj (9)
- Mode
- Middleware
- Service URL
- https://nphies.careofme.net/api/v1/nphies/send
- HTTP
- 200 in 2753 ms
- Bundle / Request
- 77919fe9-31be-42b6-82ed-37547e8b8cc8 / 762524
- Parsed items
- 0
- Total duration
- 2756 ms
- Error
- Cannot open database "NitcoSysLog" requested by the login. The login failed. Login failed for user 'NitcoWebcenter'.
{
"resourceType": "Bundle",
"id": "77919fe9-31be-42b6-82ed-37547e8b8cc8",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-30T21:17:56.14\u002B03:00",
"entry": [
{
"fullUrl": "urn:uuid:79f34fd5-94d1-4d2e-84fb-8471850fe76d",
"resource": {
"resourceType": "MessageHeader",
"id": "79f34fd5-94d1-4d2e-84fb-8471850fe76d",
"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/762524"
}
]
}
},
{
"fullUrl": "http://www.ALKholood.com/Task/762524",
"resource": {
"resourceType": "Task",
"id": "762524",
"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_920261030211756"
}
],
"status": "requested",
"intent": "order",
"priority": "stat",
"code": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-code",
"code": "poll"
}
]
},
"authoredOn": "2026-09-30",
"lastModified": "2026-10-30",
"requester": {
"reference": "Organization/9"
},
"owner": {
"identifier": {
"system": "http://nphies.sa/license/nphies",
"value": "NPHIES"
}
},
"input": [
{
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-input-type",
"code": "include-message-type"
}
]
},
"valueCode": "claim-response"
},
{
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-input-type",
"code": "period"
}
]
},
"valuePeriod": {
"start": "2026-09-30T00:00:00.000\u002B03:00",
"end": "2026-10-30T23:59:59.999\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": "77919fe9-31be-42b6-82ed-37547e8b8cc8"
}
{
"resourceType": "Bundle",
"id": "e380ca3f-ab3c-421b-99df-0cdb6de8eab5",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-30T21:17:57.296\u002B03:00",
"entry": [
{
"fullUrl": "http://nphies.sa/MessageHeader/ff553a59-4703-43ca-becb-c89629537a57",
"resource": {
"resourceType": "MessageHeader",
"id": "ff553a59-4703-43ca-becb-c89629537a57",
"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": "79f34fd5-94d1-4d2e-84fb-8471850fe76d",
"code": "ok"
}
}
},
{
"fullUrl": "http://nphies.sa/Task/f1d2054e-39c4-4910-b18f-67a9e087ef85",
"resource": {
"resourceType": "Task",
"id": "f1d2054e-39c4-4910-b18f-67a9e087ef85",
"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": "603"
}
],
"status": "completed",
"intent": "order",
"priority": "stat",
"code": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-code",
"code": "poll"
}
]
},
"authoredOn": "2026-09-30",
"lastModified": "2026-10-30",
"requester": {
"reference": "Organization/9"
},
"owner": {
"identifier": {
"system": "http://nphies.sa/license/nphies",
"value": "NPHIES"
}
},
"input": [
{
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-input-type",
"code": "include-message-type"
}
]
},
"valueCode": "claim-response"
},
{
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/task-input-type",
"code": "period"
}
]
},
"valuePeriod": {
"start": "2026-09-30T00:00:00.000\u002B03:00",
"end": "2026-10-30T23:59:59.999\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": "2026-10-20T08:53:35.842\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/dfe4b062-2df9-48f0-87d4-d901f4514408"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:35.847\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/7b0b2bec-3aba-4470-b747-8587b6e05e1e"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:35.963\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/634e748e-0d0a-4ae6-9189-8f895d615ab7"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:36.002\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/de3a48d0-6d44-47a1-9aea-7fd97ef0e6d2"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:36.008\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/759d390f-f5eb-4610-9917-c0d84d255b3b"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:36.011\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/543764fe-d799-4087-b07c-36f5c27d4147"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:36.017\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/7ca3932f-26e9-4546-9aef-35ca3a206aca"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:36.028\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/68328ed9-42f2-4370-bed7-289575f9f95a"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:36.037\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/a2d1b8ee-389d-461f-8715-900df1d85c87"
}
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-timestamp",
"valueDateTime": "2026-10-20T08:53:36.051\u002B00:00"
}
],
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/ValueSet/task-output-type",
"code": "response"
}
]
},
"valueReference": {
"reference": "http://nphies.sa/Bundle/94a560bb-7e25-4f4b-9caa-6caed5744fcb"
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/dfe4b062-2df9-48f0-87d4-d901f4514408",
"resource": {
"resourceType": "Bundle",
"id": "dfe4b062-2df9-48f0-87d4-d901f4514408",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:34.954\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/4b02343d-e59e-452a-825b-c5687fec260c",
"resource": {
"resourceType": "MessageHeader",
"id": "4b02343d-e59e-452a-825b-c5687fec260c",
"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": "990b195a-9c9e-4b0c-837e-aa98a3d820c5",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/9fee8360-29f6-4962-a668-11faf9e0978f"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/9fee8360-29f6-4962-a668-11faf9e0978f",
"resource": {
"resourceType": "ClaimResponse",
"id": "9fee8360-29f6-4962-a668-11faf9e0978f",
"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": "2689"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "9fee8360-29f6-4962-a668-11faf9e0978f"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/94f654d5-7d90-4381-8ac6-a75182b3160e"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/16a2575d-1df7-4ec1-a74a-ff214ab57137"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/e5453be2-cba9-4c54-9c2c-9f218724425b"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "21295310260930"
}
},
"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": "103701"
}
}
],
"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": 11.11,
"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": 2.22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 11.11,
"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": "103701"
}
}
],
"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": 4.54,
"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": 4.54,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 0.91,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 3.63,
"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": "103701"
}
}
],
"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": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 1.59,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 7.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 7.96,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 6.37,
"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": "103701"
}
}
],
"itemSequence": 4,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 8.37,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 6.64,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 0.74,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 8.37,
"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://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": "103701"
}
}
],
"itemSequence": 5,
"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": "CV-4-5"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 9.63,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 1.93,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 9.63,
"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": "103701"
}
}
],
"itemSequence": 6,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 40.77,
"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": 40.77,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "MN-1-1"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 0
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "103701"
}
}
],
"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": 31.72,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 6.34,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 31.72,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 25.38,
"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": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 114.1,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 42.02,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 21.88,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 114.1,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/cfd8b438-e9a6-42f0-bdcc-a3637700cef9"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/94f654d5-7d90-4381-8ac6-a75182b3160e",
"resource": {
"resourceType": "Patient",
"id": "94f654d5-7d90-4381-8ac6-a75182b3160e",
"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": "1001156460"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "HAMIDAH MOSLEH SUWELAH ALLAHIBI",
"given": [
"HAMIDAH",
"SUWELAH",
"ALLAHIBI"
]
}
],
"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": "1960-12-19",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/e5453be2-cba9-4c54-9c2c-9f218724425b",
"resource": {
"resourceType": "Organization",
"id": "e5453be2-cba9-4c54-9c2c-9f218724425b",
"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/16a2575d-1df7-4ec1-a74a-ff214ab57137",
"resource": {
"resourceType": "Organization",
"id": "16a2575d-1df7-4ec1-a74a-ff214ab57137",
"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/cfd8b438-e9a6-42f0-bdcc-a3637700cef9",
"resource": {
"resourceType": "Coverage",
"id": "cfd8b438-e9a6-42f0-bdcc-a3637700cef9",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "001001156486511"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/ff2ed253-d1e0-4404-9d7b-ad42171b3d2a"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/f7200028-82fb-40d3-9f58-a84c02d10bc3"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/94f654d5-7d90-4381-8ac6-a75182b3160e"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/16a2575d-1df7-4ec1-a74a-ff214ab57137"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "2123",
"name": "NATIONAL WATER COMPANY"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/ff2ed253-d1e0-4404-9d7b-ad42171b3d2a",
"resource": {
"resourceType": "Organization",
"id": "ff2ed253-d1e0-4404-9d7b-ad42171b3d2a",
"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/f7200028-82fb-40d3-9f58-a84c02d10bc3",
"resource": {
"resourceType": "Patient",
"id": "f7200028-82fb-40d3-9f58-a84c02d10bc3",
"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": "1001156460"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "HAMIDAH MOSLEH SUWELAH ALLAHIBI",
"given": [
"HAMIDAH",
"SUWELAH",
"ALLAHIBI"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0550838257"
}
],
"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": "1960-12-19",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/7b0b2bec-3aba-4470-b747-8587b6e05e1e",
"resource": {
"resourceType": "Bundle",
"id": "7b0b2bec-3aba-4470-b747-8587b6e05e1e",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:32.684\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/e40b45e7-4052-4092-b22f-0ca303dcd26d",
"resource": {
"resourceType": "MessageHeader",
"id": "e40b45e7-4052-4092-b22f-0ca303dcd26d",
"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": "b9ebf856-8d95-413b-9b01-6afdf58dce67",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/26602ba2-305f-4aa9-8aaa-9212f2505fbe"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/26602ba2-305f-4aa9-8aaa-9212f2505fbe",
"resource": {
"resourceType": "ClaimResponse",
"id": "26602ba2-305f-4aa9-8aaa-9212f2505fbe",
"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": "1166"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "26602ba2-305f-4aa9-8aaa-9212f2505fbe"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/9ead284a-93a5-4c10-b70d-65c6f2242188"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/19f1bb98-e689-4f63-9c3a-49fb1086f3b3"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/559614e1-5511-4c1b-892f-f22e05ce4afe"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "2251804260914"
}
},
"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": "87621"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 20.52,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 25.65,
"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": 25.65,
"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": "copay"
}
]
},
"amount": {
"value": 5.13,
"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": "87621"
}
}
],
"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"
}
]
},
"amount": {
"value": 11.38,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 2.84,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 14.22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 14.22,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 39.87,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 31.9,
"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": 7.97,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 39.87,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/065d2364-4d20-4e31-a08e-3bc033a27f7c"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/9ead284a-93a5-4c10-b70d-65c6f2242188",
"resource": {
"resourceType": "Patient",
"id": "9ead284a-93a5-4c10-b70d-65c6f2242188",
"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": "2439932415"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "MD Mostfidal Mostfidal hussain",
"given": [
"MD",
"Mostfidal",
"hussain"
]
}
],
"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": "1987-07-12",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/559614e1-5511-4c1b-892f-f22e05ce4afe",
"resource": {
"resourceType": "Organization",
"id": "559614e1-5511-4c1b-892f-f22e05ce4afe",
"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/19f1bb98-e689-4f63-9c3a-49fb1086f3b3",
"resource": {
"resourceType": "Organization",
"id": "19f1bb98-e689-4f63-9c3a-49fb1086f3b3",
"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/065d2364-4d20-4e31-a08e-3bc033a27f7c",
"resource": {
"resourceType": "Coverage",
"id": "065d2364-4d20-4e31-a08e-3bc033a27f7c",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002439932415001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/30cc7494-508b-4dc8-93b0-cdb5d11503b2"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/86df3379-630a-4aca-b32a-00ea6b3ab6a0"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/9ead284a-93a5-4c10-b70d-65c6f2242188"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/19f1bb98-e689-4f63-9c3a-49fb1086f3b3"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "53176838",
"name": "POWER AND WATER TECHNOLOGY AWPT"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/30cc7494-508b-4dc8-93b0-cdb5d11503b2",
"resource": {
"resourceType": "Organization",
"id": "30cc7494-508b-4dc8-93b0-cdb5d11503b2",
"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/86df3379-630a-4aca-b32a-00ea6b3ab6a0",
"resource": {
"resourceType": "Patient",
"id": "86df3379-630a-4aca-b32a-00ea6b3ab6a0",
"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": "2439932415"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "MD Mostfidal Mostfidal hussain",
"given": [
"MD",
"Mostfidal",
"hussain"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0573438821"
}
],
"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": "1987-07-12",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/634e748e-0d0a-4ae6-9189-8f895d615ab7",
"resource": {
"resourceType": "Bundle",
"id": "634e748e-0d0a-4ae6-9189-8f895d615ab7",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:32.596\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/0fbf2a6d-f9f1-4494-ba3b-44aaf457c368",
"resource": {
"resourceType": "MessageHeader",
"id": "0fbf2a6d-f9f1-4494-ba3b-44aaf457c368",
"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": "b255eebf-fd63-471c-b8c6-7ad9f710a3ff",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/d875140a-9fb9-4fd2-b619-646610be1b8a"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/d875140a-9fb9-4fd2-b619-646610be1b8a",
"resource": {
"resourceType": "ClaimResponse",
"id": "d875140a-9fb9-4fd2-b619-646610be1b8a",
"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": "rejected"
}
]
}
},
{
"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": "1436"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "d875140a-9fb9-4fd2-b619-646610be1b8a"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/03244730-eef0-4116-aeeb-050400c84dce"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/a168167d-bbb9-4704-ae35-78e62750143b"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/8bc1e436-058b-46fd-a6c5-257c469f98c9"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "73259734260917"
}
},
"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": "90547"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"code": "AD-2-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 8.19,
"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": 8.19,
"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": 1.64,
"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": "90547"
}
}
],
"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-2-4"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 1.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 7.02,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 7.02,
"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": 15.21,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 3.04,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 15.21,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/a9c61751-4fc6-45b4-b751-78ee8f00dd88"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/03244730-eef0-4116-aeeb-050400c84dce",
"resource": {
"resourceType": "Patient",
"id": "03244730-eef0-4116-aeeb-050400c84dce",
"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": "2153042011"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "reem MORAD muhammad",
"given": [
"reem",
"MORAD",
"muhammad"
]
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "1997-05-07",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/8bc1e436-058b-46fd-a6c5-257c469f98c9",
"resource": {
"resourceType": "Organization",
"id": "8bc1e436-058b-46fd-a6c5-257c469f98c9",
"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/a168167d-bbb9-4704-ae35-78e62750143b",
"resource": {
"resourceType": "Organization",
"id": "a168167d-bbb9-4704-ae35-78e62750143b",
"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/a9c61751-4fc6-45b4-b751-78ee8f00dd88",
"resource": {
"resourceType": "Coverage",
"id": "a9c61751-4fc6-45b4-b751-78ee8f00dd88",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "001095302657101"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/b07dff3a-406b-480c-b6d8-6ed619ce46ae"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/ecde73f4-4935-4918-ac80-ce8e2168a585"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/03244730-eef0-4116-aeeb-050400c84dce"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/a168167d-bbb9-4704-ae35-78e62750143b"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "54273730",
"name": "LEEJAM SPORTS COMPANY"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/b07dff3a-406b-480c-b6d8-6ed619ce46ae",
"resource": {
"resourceType": "Organization",
"id": "b07dff3a-406b-480c-b6d8-6ed619ce46ae",
"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/ecde73f4-4935-4918-ac80-ce8e2168a585",
"resource": {
"resourceType": "Patient",
"id": "ecde73f4-4935-4918-ac80-ce8e2168a585",
"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": "2153042011"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "reem MORAD muhammad",
"given": [
"reem",
"MORAD",
"muhammad"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0566054030"
}
],
"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": "1997-05-07",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/de3a48d0-6d44-47a1-9aea-7fd97ef0e6d2",
"resource": {
"resourceType": "Bundle",
"id": "de3a48d0-6d44-47a1-9aea-7fd97ef0e6d2",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:35.460\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/830dd03c-911f-4a4d-b9c5-e082bb758d24",
"resource": {
"resourceType": "MessageHeader",
"id": "830dd03c-911f-4a4d-b9c5-e082bb758d24",
"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": "d9446ae3-3d14-48c7-84a7-28061afc9e6d",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/c203dc98-0d47-426e-b16b-0d04754a2052"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/c203dc98-0d47-426e-b16b-0d04754a2052",
"resource": {
"resourceType": "ClaimResponse",
"id": "c203dc98-0d47-426e-b16b-0d04754a2052",
"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": "2539"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "c203dc98-0d47-426e-b16b-0d04754a2052"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/8ff9b8d0-2e16-4e97-81f7-beae65bf10ad"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/a11a4a28-a7fc-41d2-8175-285e8f202ac9"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/071d38fb-edd0-4def-b3f6-65fac0ca1da8"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "30290829260929"
}
},
"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": "102213"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 4.03,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 5.04,
"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": 1.01,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 5.04,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "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": "102213"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 4.54,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 0.91,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 4.54,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 3.63,
"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://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": "102213"
}
}
],
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 46.03,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 36.82,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 9.21,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 46.03,
"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": 55.61,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 44.48,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 11.13,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 55.61,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/a3b635f1-4c9a-4951-ab03-42c90ec9f93a"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/8ff9b8d0-2e16-4e97-81f7-beae65bf10ad",
"resource": {
"resourceType": "Patient",
"id": "8ff9b8d0-2e16-4e97-81f7-beae65bf10ad",
"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": "2305310258"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "ABDULRAHMAN yehia sgr",
"given": [
"ABDULRAHMAN",
"yehia",
"sgr"
]
}
],
"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": "1986-11-19",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/071d38fb-edd0-4def-b3f6-65fac0ca1da8",
"resource": {
"resourceType": "Organization",
"id": "071d38fb-edd0-4def-b3f6-65fac0ca1da8",
"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/a11a4a28-a7fc-41d2-8175-285e8f202ac9",
"resource": {
"resourceType": "Organization",
"id": "a11a4a28-a7fc-41d2-8175-285e8f202ac9",
"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/a3b635f1-4c9a-4951-ab03-42c90ec9f93a",
"resource": {
"resourceType": "Coverage",
"id": "a3b635f1-4c9a-4951-ab03-42c90ec9f93a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002305310258001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/0aac6d49-1848-440a-aa0d-2b5214126c7c"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/ed546c18-42ca-4ea6-a221-3b20fc25e0ca"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/8ff9b8d0-2e16-4e97-81f7-beae65bf10ad"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/a11a4a28-a7fc-41d2-8175-285e8f202ac9"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "57112002",
"name": "ABDULLAH I ALSUBEAEI RE DEV"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/0aac6d49-1848-440a-aa0d-2b5214126c7c",
"resource": {
"resourceType": "Organization",
"id": "0aac6d49-1848-440a-aa0d-2b5214126c7c",
"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/ed546c18-42ca-4ea6-a221-3b20fc25e0ca",
"resource": {
"resourceType": "Patient",
"id": "ed546c18-42ca-4ea6-a221-3b20fc25e0ca",
"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": "2305310258"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "ABDULRAHMAN yehia sgr",
"given": [
"ABDULRAHMAN",
"yehia",
"sgr"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0560911867"
}
],
"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": "1986-11-19",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/759d390f-f5eb-4610-9917-c0d84d255b3b",
"resource": {
"resourceType": "Bundle",
"id": "759d390f-f5eb-4610-9917-c0d84d255b3b",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:35.436\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/7c92e726-1972-43d1-80dd-67a90328f523",
"resource": {
"resourceType": "MessageHeader",
"id": "7c92e726-1972-43d1-80dd-67a90328f523",
"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": "1c2e2299-a865-4eaf-aa81-58ca0dba0343",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/68683ba0-50db-475e-8d58-8d7a44dbce9c"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/68683ba0-50db-475e-8d58-8d7a44dbce9c",
"resource": {
"resourceType": "ClaimResponse",
"id": "68683ba0-50db-475e-8d58-8d7a44dbce9c",
"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": "2402"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "68683ba0-50db-475e-8d58-8d7a44dbce9c"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/1e45bd7d-15b3-479b-9e96-c82e00def50d"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/2686dfe5-d753-4207-b81c-75190f8a2f03"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/339319c3-bdbf-454b-924b-1d89b9feb611"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "28286350260928"
}
},
"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": "100787"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 10.53,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 2.11,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 10.53,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 8.42,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://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": "100787"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 24.97,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 24.97,
"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": "benefit"
}
]
},
"amount": {
"value": 19.98,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 4.99,
"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": "100787"
}
}
],
"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": "eligible"
}
]
},
"amount": {
"value": 12.1,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 2.42,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 12.1,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 9.68,
"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": 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": "100787"
}
}
],
"itemSequence": 4,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 10.44,
"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": 2.61,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 13.05,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 13.05,
"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": 60.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 48.52,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 12.13,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 60.65,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/afe1e6e4-ee01-45c9-a474-ed162055f1ca"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/1e45bd7d-15b3-479b-9e96-c82e00def50d",
"resource": {
"resourceType": "Patient",
"id": "1e45bd7d-15b3-479b-9e96-c82e00def50d",
"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": "2350644957"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "SAFAA MOHAMMED BADR QATRJY",
"given": [
"SAFAA",
"BADR",
"QATRJY"
]
}
],
"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": "1951-04-12",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/339319c3-bdbf-454b-924b-1d89b9feb611",
"resource": {
"resourceType": "Organization",
"id": "339319c3-bdbf-454b-924b-1d89b9feb611",
"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/2686dfe5-d753-4207-b81c-75190f8a2f03",
"resource": {
"resourceType": "Organization",
"id": "2686dfe5-d753-4207-b81c-75190f8a2f03",
"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/afe1e6e4-ee01-45c9-a474-ed162055f1ca",
"resource": {
"resourceType": "Coverage",
"id": "afe1e6e4-ee01-45c9-a474-ed162055f1ca",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002019768544101"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/6951601f-bb24-4763-be63-e4474233c6b3"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/46ccf762-7f54-468c-9ab0-bc502268ed3d"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/1e45bd7d-15b3-479b-9e96-c82e00def50d"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/2686dfe5-d753-4207-b81c-75190f8a2f03"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "54373369",
"name": "Al Tawfiq Al Mumayaz Basic"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/6951601f-bb24-4763-be63-e4474233c6b3",
"resource": {
"resourceType": "Organization",
"id": "6951601f-bb24-4763-be63-e4474233c6b3",
"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/46ccf762-7f54-468c-9ab0-bc502268ed3d",
"resource": {
"resourceType": "Patient",
"id": "46ccf762-7f54-468c-9ab0-bc502268ed3d",
"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": "2350644957"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "SAFAA MOHAMMED BADR QATRJY",
"given": [
"SAFAA",
"BADR",
"QATRJY"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0535199688"
}
],
"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": "1951-04-12",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/543764fe-d799-4087-b07c-36f5c27d4147",
"resource": {
"resourceType": "Bundle",
"id": "543764fe-d799-4087-b07c-36f5c27d4147",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:35.402\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/8e336a76-4939-4d75-9da2-da04a99b2aa7",
"resource": {
"resourceType": "MessageHeader",
"id": "8e336a76-4939-4d75-9da2-da04a99b2aa7",
"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": "60161010-d3e8-4796-a58c-fd1d6374a714",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/ac00943d-a917-46fc-adb0-0f96d23c4972"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/ac00943d-a917-46fc-adb0-0f96d23c4972",
"resource": {
"resourceType": "ClaimResponse",
"id": "ac00943d-a917-46fc-adb0-0f96d23c4972",
"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": "2702"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "ac00943d-a917-46fc-adb0-0f96d23c4972"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/4f6f6e7f-9f13-4f03-8217-1139a10e2dff"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/690b4ccf-cda8-41e5-b9e5-b33d3421be44"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/cf947a68-692c-43d5-a261-9a9fdff0ff8a"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "72295797260930"
}
},
"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": "103853"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 32.58,
"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": 32.58,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 26.06,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 6.52,
"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": "103853"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 3.03,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 15.16,
"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": 15.16,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 12.13,
"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": "103853"
}
}
],
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 6.48,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 6.48,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 1.3,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 5.18,
"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": "103853"
}
}
],
"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": 17.43,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 3.11,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 17.43,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 12.46,
"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": 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": "103853"
}
}
],
"itemSequence": 5,
"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": "eligible"
}
]
},
"amount": {
"value": 40.14,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.03,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 40.14,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 32.11,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 111.79,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 87.94,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 21.99,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 111.79,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/8e787af7-aebf-4798-ae49-ea0bff4d507c"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/4f6f6e7f-9f13-4f03-8217-1139a10e2dff",
"resource": {
"resourceType": "Patient",
"id": "4f6f6e7f-9f13-4f03-8217-1139a10e2dff",
"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": "2377085549"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "talal radi MANSOR nasr",
"given": [
"talal",
"MANSOR",
"nasr"
]
}
],
"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": "1981-11-01",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/cf947a68-692c-43d5-a261-9a9fdff0ff8a",
"resource": {
"resourceType": "Organization",
"id": "cf947a68-692c-43d5-a261-9a9fdff0ff8a",
"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/690b4ccf-cda8-41e5-b9e5-b33d3421be44",
"resource": {
"resourceType": "Organization",
"id": "690b4ccf-cda8-41e5-b9e5-b33d3421be44",
"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/8e787af7-aebf-4798-ae49-ea0bff4d507c",
"resource": {
"resourceType": "Coverage",
"id": "8e787af7-aebf-4798-ae49-ea0bff4d507c",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002377085549001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/46af304b-8efe-4733-a5e1-f2acde8922d3"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/627c7435-9b33-44ee-b7bb-8a2179560942"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/4f6f6e7f-9f13-4f03-8217-1139a10e2dff"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/690b4ccf-cda8-41e5-b9e5-b33d3421be44"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "55344534",
"name": "Golden Joudy Company Basic B"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/46af304b-8efe-4733-a5e1-f2acde8922d3",
"resource": {
"resourceType": "Organization",
"id": "46af304b-8efe-4733-a5e1-f2acde8922d3",
"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/627c7435-9b33-44ee-b7bb-8a2179560942",
"resource": {
"resourceType": "Patient",
"id": "627c7435-9b33-44ee-b7bb-8a2179560942",
"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": "2377085549"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "talal radi MANSOR nasr",
"given": [
"talal",
"MANSOR",
"nasr"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0554308461"
}
],
"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": "1981-11-01",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/7ca3932f-26e9-4546-9aef-35ca3a206aca",
"resource": {
"resourceType": "Bundle",
"id": "7ca3932f-26e9-4546-9aef-35ca3a206aca",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:35.655\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/b9209b75-6a8e-40cf-bdcd-6c3c847c9f9c",
"resource": {
"resourceType": "MessageHeader",
"id": "b9209b75-6a8e-40cf-bdcd-6c3c847c9f9c",
"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": "2c99e654-b981-4888-9e0d-5bd0379e3827",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/f6947787-97f8-4f5c-a93c-799fe3b97608"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/f6947787-97f8-4f5c-a93c-799fe3b97608",
"resource": {
"resourceType": "ClaimResponse",
"id": "f6947787-97f8-4f5c-a93c-799fe3b97608",
"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": "2420"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "f6947787-97f8-4f5c-a93c-799fe3b97608"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/13c1542a-2886-4cd0-ac4f-ac109151b16a"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/2f232274-bac2-4e4d-b47a-94e223e6c01b"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/920e93ca-0416-4701-9f18-d6e826a71643"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "69286665260928"
}
},
"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": "100919"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 27.1,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 33.88,
"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": 6.78,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 33.88,
"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": "100919"
}
}
],
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 43.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 8.64,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 43.2,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 34.56,
"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://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 2
}
]
},
{
"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": "100919"
}
}
],
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 29.25,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 23.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.85,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 29.25,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 2
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 106.33,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 85.06,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 21.27,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 106.33,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/128359f1-b18f-4531-9ff3-b1507a1092fd"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/13c1542a-2886-4cd0-ac4f-ac109151b16a",
"resource": {
"resourceType": "Patient",
"id": "13c1542a-2886-4cd0-ac4f-ac109151b16a",
"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": "1050080363"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "AISHA MOHAMMED MADENI HAFEZ",
"given": [
"AISHA",
"MADENI",
"HAFEZ"
]
}
],
"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": "1959-12-30",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/920e93ca-0416-4701-9f18-d6e826a71643",
"resource": {
"resourceType": "Organization",
"id": "920e93ca-0416-4701-9f18-d6e826a71643",
"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/2f232274-bac2-4e4d-b47a-94e223e6c01b",
"resource": {
"resourceType": "Organization",
"id": "2f232274-bac2-4e4d-b47a-94e223e6c01b",
"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/128359f1-b18f-4531-9ff3-b1507a1092fd",
"resource": {
"resourceType": "Coverage",
"id": "128359f1-b18f-4531-9ff3-b1507a1092fd",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "001076650777511"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/8c5c243c-60c6-4a76-b008-b9678b23dc5c"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/16e6b691-a376-4702-a76e-9aa96264a573"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/13c1542a-2886-4cd0-ac4f-ac109151b16a"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/2f232274-bac2-4e4d-b47a-94e223e6c01b"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "56651214",
"name": "SAUDI GROUND SERVICES CO"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/8c5c243c-60c6-4a76-b008-b9678b23dc5c",
"resource": {
"resourceType": "Organization",
"id": "8c5c243c-60c6-4a76-b008-b9678b23dc5c",
"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/16e6b691-a376-4702-a76e-9aa96264a573",
"resource": {
"resourceType": "Patient",
"id": "16e6b691-a376-4702-a76e-9aa96264a573",
"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": "1050080363"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "AISHA MOHAMMED MADENI HAFEZ",
"given": [
"AISHA",
"MADENI",
"HAFEZ"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0543016653"
}
],
"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": "1959-12-30",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/68328ed9-42f2-4370-bed7-289575f9f95a",
"resource": {
"resourceType": "Bundle",
"id": "68328ed9-42f2-4370-bed7-289575f9f95a",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:35.641\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/2eb61d65-de4a-40f4-a8c0-93346cb92f7d",
"resource": {
"resourceType": "MessageHeader",
"id": "2eb61d65-de4a-40f4-a8c0-93346cb92f7d",
"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": "6999c3bc-d57d-404c-bb0c-4aa2edb7adaf",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/89257352-d0df-4f2d-bca2-0b122d71d283"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/89257352-d0df-4f2d-bca2-0b122d71d283",
"resource": {
"resourceType": "ClaimResponse",
"id": "89257352-d0df-4f2d-bca2-0b122d71d283",
"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": "rejected"
}
]
}
},
{
"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": "2640"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "89257352-d0df-4f2d-bca2-0b122d71d283"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/57449132-47a9-4ab0-9dc5-0761452ea594"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/52fc3e19-2311-4beb-b24a-b462e51da9c1"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/3768ec09-d738-4b70-9479-07d48a7b3705"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "41293974260930"
}
},
"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": "103224"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 18.9,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 3.78,
"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": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 18.9,
"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": 18.9,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 3.78,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 18.9,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/f5a19f71-6dc2-4865-84a6-1700b688c5e4"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/57449132-47a9-4ab0-9dc5-0761452ea594",
"resource": {
"resourceType": "Patient",
"id": "57449132-47a9-4ab0-9dc5-0761452ea594",
"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": "1104709488"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "NUHA muhammad alghamdi",
"given": [
"NUHA",
"alghamdi",
"alghamdi"
]
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "1999-07-30",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/3768ec09-d738-4b70-9479-07d48a7b3705",
"resource": {
"resourceType": "Organization",
"id": "3768ec09-d738-4b70-9479-07d48a7b3705",
"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/52fc3e19-2311-4beb-b24a-b462e51da9c1",
"resource": {
"resourceType": "Organization",
"id": "52fc3e19-2311-4beb-b24a-b462e51da9c1",
"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/f5a19f71-6dc2-4865-84a6-1700b688c5e4",
"resource": {
"resourceType": "Coverage",
"id": "f5a19f71-6dc2-4865-84a6-1700b688c5e4",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "001089187296101"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/d29325b2-af0e-4b67-848e-c30ff9b10e92"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/9dacfb30-414b-4ed2-b8d5-8b388bbc33ac"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/57449132-47a9-4ab0-9dc5-0761452ea594"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/52fc3e19-2311-4beb-b24a-b462e51da9c1"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "55016630",
"name": "united electronics campany"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/d29325b2-af0e-4b67-848e-c30ff9b10e92",
"resource": {
"resourceType": "Organization",
"id": "d29325b2-af0e-4b67-848e-c30ff9b10e92",
"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/9dacfb30-414b-4ed2-b8d5-8b388bbc33ac",
"resource": {
"resourceType": "Patient",
"id": "9dacfb30-414b-4ed2-b8d5-8b388bbc33ac",
"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": "1104709488"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "NUHA muhammad alghamdi",
"given": [
"NUHA",
"alghamdi",
"alghamdi"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0538356841"
}
],
"gender": "female",
"_gender": {
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-ksa-administrative-gender",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-administrative-gender",
"code": "female",
"display": "female"
}
]
}
}
]
},
"birthDate": "1999-07-30",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/a2d1b8ee-389d-461f-8715-900df1d85c87",
"resource": {
"resourceType": "Bundle",
"id": "a2d1b8ee-389d-461f-8715-900df1d85c87",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:35.421\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/584cd143-bd85-444a-ab8a-d5f0168f15ec",
"resource": {
"resourceType": "MessageHeader",
"id": "584cd143-bd85-444a-ab8a-d5f0168f15ec",
"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": "f671189b-bf7a-4aac-b40e-d88cff1c53f2",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/d160a877-0e3a-4739-9255-822b9bb133b3"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/d160a877-0e3a-4739-9255-822b9bb133b3",
"resource": {
"resourceType": "ClaimResponse",
"id": "d160a877-0e3a-4739-9255-822b9bb133b3",
"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": "2653"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "d160a877-0e3a-4739-9255-822b9bb133b3"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/aee91a8f-0451-4259-894e-93729ffab379"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/8a76cd4e-74dc-46e1-bdac-bb832284a80e"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/ab0db2a0-2021-484c-8751-d57bf45a8269"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "42294212260930"
}
},
"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": "103290"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 5.62,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 7.02,
"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": 7.02,
"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": 1.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "103290"
}
}
],
"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"
}
]
},
"amount": {
"value": 20.95,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 5.24,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 26.19,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 26.19,
"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": 33.21,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 26.57,
"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": 6.64,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 33.21,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/99735595-e3e1-4e06-a6b0-5f7122845d52"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/aee91a8f-0451-4259-894e-93729ffab379",
"resource": {
"resourceType": "Patient",
"id": "aee91a8f-0451-4259-894e-93729ffab379",
"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": "2300130057"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "ahmed SABRI abdalhafd",
"given": [
"ahmed",
"SABRI",
"abdalhafd"
]
}
],
"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": "1977-06-20",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/ab0db2a0-2021-484c-8751-d57bf45a8269",
"resource": {
"resourceType": "Organization",
"id": "ab0db2a0-2021-484c-8751-d57bf45a8269",
"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/8a76cd4e-74dc-46e1-bdac-bb832284a80e",
"resource": {
"resourceType": "Organization",
"id": "8a76cd4e-74dc-46e1-bdac-bb832284a80e",
"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/99735595-e3e1-4e06-a6b0-5f7122845d52",
"resource": {
"resourceType": "Coverage",
"id": "99735595-e3e1-4e06-a6b0-5f7122845d52",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002300130057001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/1f3e0108-bc01-474f-b9dc-3fa4e9888654"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/40edd084-d21f-4cc8-975c-f82ccceb2f91"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/aee91a8f-0451-4259-894e-93729ffab379"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/8a76cd4e-74dc-46e1-bdac-bb832284a80e"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "57953043",
"name": "Sana Creativity Co Ltd"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/1f3e0108-bc01-474f-b9dc-3fa4e9888654",
"resource": {
"resourceType": "Organization",
"id": "1f3e0108-bc01-474f-b9dc-3fa4e9888654",
"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/40edd084-d21f-4cc8-975c-f82ccceb2f91",
"resource": {
"resourceType": "Patient",
"id": "40edd084-d21f-4cc8-975c-f82ccceb2f91",
"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": "2300130057"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "ahmed SABRI abdalhafd",
"given": [
"ahmed",
"SABRI",
"abdalhafd"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0596825385"
}
],
"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": "1977-06-20",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
}
]
}
},
{
"fullUrl": "http://nphies.sa/Bundle/94a560bb-7e25-4f4b-9caa-6caed5744fcb",
"resource": {
"resourceType": "Bundle",
"id": "94a560bb-7e25-4f4b-9caa-6caed5744fcb",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/bundle|1.0.0"
]
},
"type": "message",
"timestamp": "2026-10-20T11:53:35.668\u002B03:00",
"entry": [
{
"fullUrl": "https://tawuniya.com.sa/MessageHeader/1bc3488c-08e8-46ac-8fb1-ae0682557d08",
"resource": {
"resourceType": "MessageHeader",
"id": "1bc3488c-08e8-46ac-8fb1-ae0682557d08",
"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": "2a08d401-84c5-48e4-a466-a880b9f904b9",
"code": "ok"
},
"focus": [
{
"reference": "https://tawuniya.com.sa/ClaimResponse/3f45ade1-2a66-4005-b253-c5ddbd30c3f7"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/ClaimResponse/3f45ade1-2a66-4005-b253-c5ddbd30c3f7",
"resource": {
"resourceType": "ClaimResponse",
"id": "3f45ade1-2a66-4005-b253-c5ddbd30c3f7",
"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": "2424"
}
}
],
"identifier": [
{
"system": "https://tawuniya.com.sa/claimResponse",
"value": "3f45ade1-2a66-4005-b253-c5ddbd30c3f7"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/claim-subtype",
"code": "op"
}
]
},
"use": "claim",
"patient": {
"reference": "https://tawuniya.com.sa/Patient/0ba90d5c-72d9-42a7-bb33-07318dfcf894"
},
"created": "2026-10-20",
"insurer": {
"reference": "https://tawuniya.com.sa/Organization/31eba6ed-d911-429a-9cb8-756803eeada1"
},
"requestor": {
"reference": "https://tawuniya.com.sa/Organization/5f23bf33-dfd8-44d7-b596-1cae534bd84c"
},
"request": {
"identifier": {
"system": "http://www.ALKholood.com/claim",
"value": "79286713260928"
}
},
"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": "100937"
}
}
],
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 41.62,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 52.02,
"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": 52.02,
"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": 10.4,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/ksa-adjudication",
"code": "approved-quantity"
}
]
},
"value": 1
}
]
},
{
"extension": [
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome",
"valueCodeableConcept": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/adjudication-outcome",
"code": "approved"
}
]
}
},
{
"url": "http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice",
"valueIdentifier": {
"system": "http://www.ALKholood.com/patientInvoice",
"value": "100937"
}
}
],
"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"
}
]
},
"amount": {
"value": 3.63,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 0.91,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted"
}
]
},
"amount": {
"value": 4.54,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 4.54,
"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": 56.56,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit"
}
]
},
"amount": {
"value": 45.25,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "deductible"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay"
}
]
},
"amount": {
"value": 11.31,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible"
}
]
},
"amount": {
"value": 56.56,
"currency": "SAR"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "tax"
}
]
},
"amount": {
"value": 0,
"currency": "SAR"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "https://tawuniya.com.sa/Coverage/ac7d64c8-f481-4dec-a99e-0ff3fbad4f75"
}
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Patient/0ba90d5c-72d9-42a7-bb33-07318dfcf894",
"resource": {
"resourceType": "Patient",
"id": "0ba90d5c-72d9-42a7-bb33-07318dfcf894",
"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": "2285378754"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "MOHAMMED JUMAA MUHAMMAD",
"given": [
"MOHAMMED",
"MUHAMMAD",
"MUHAMMAD"
]
}
],
"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": "1988-10-25",
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "M"
}
]
}
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/5f23bf33-dfd8-44d7-b596-1cae534bd84c",
"resource": {
"resourceType": "Organization",
"id": "5f23bf33-dfd8-44d7-b596-1cae534bd84c",
"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/31eba6ed-d911-429a-9cb8-756803eeada1",
"resource": {
"resourceType": "Organization",
"id": "31eba6ed-d911-429a-9cb8-756803eeada1",
"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/ac7d64c8-f481-4dec-a99e-0ff3fbad4f75",
"resource": {
"resourceType": "Coverage",
"id": "ac7d64c8-f481-4dec-a99e-0ff3fbad4f75",
"meta": {
"profile": [
"http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/coverage|1.0.0"
]
},
"identifier": [
{
"system": "https://tawuniya.com.sa/memberid",
"value": "002285378754001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://nphies.sa/terminology/CodeSystem/coverage-type",
"code": "EHCPOL"
}
]
},
"policyHolder": {
"reference": "https://tawuniya.com.sa/Organization/e10df01d-cb59-45c5-b1b1-f1a62bb8ee60"
},
"subscriber": {
"reference": "https://tawuniya.com.sa/Patient/f99b187b-50e9-4dbe-b472-3595673f37db"
},
"beneficiary": {
"reference": "https://tawuniya.com.sa/Patient/0ba90d5c-72d9-42a7-bb33-07318dfcf894"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "self"
}
]
},
"payor": [
{
"reference": "https://tawuniya.com.sa/Organization/31eba6ed-d911-429a-9cb8-756803eeada1"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan"
}
]
},
"value": "50765128",
"name": "MOHAMED ABDULLAH ALS Basic B"
}
]
}
},
{
"fullUrl": "https://tawuniya.com.sa/Organization/e10df01d-cb59-45c5-b1b1-f1a62bb8ee60",
"resource": {
"resourceType": "Organization",
"id": "e10df01d-cb59-45c5-b1b1-f1a62bb8ee60",
"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/f99b187b-50e9-4dbe-b472-3595673f37db",
"resource": {
"resourceType": "Patient",
"id": "f99b187b-50e9-4dbe-b472-3595673f37db",
"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": "2285378754"
}
],
"active": true,
"name": [
{
"use": "official",
"text": "MOHAMMED JUMAA MUHAMMAD",
"given": [
"MOHAMMED",
"MUHAMMAD",
"MUHAMMAD"
]
}
],
"telecom": [
{
"system": "phone",
"value": "0535016643"
}
],
"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": "1988-10-25",
"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.