Kenya eClaims FHIR Implementation Guide
0.1.0 - ci-build Kenya flag

Kenya eClaims FHIR Implementation Guide, published by Digital Health Agency of Kenya. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IntelliSOFT-Consulting/Kenya-eClaims-FHIR-IG/ and changes regularly. See the Directory of published versions

: Example Oncology Preauthorization - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <id value="ECLM-ONC-001"/>
  <meta>
    <profile
             value="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/ke-eclaims-oncologypreauth"/>
    <tag>
      <system value="http://terminology.hl7.org/CodeSystem/common-tags"/>
      <code value="actionable"/>
      <display value="Actionable"/>
    </tag>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim ECLM-ONC-001</b></p><a name="ECLM-ONC-001"> </a><a name="hcECLM-ONC-001"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ke-eclaims-oncologypreauth.html">Oncology Preauthorization</a></p><p style="margin-bottom: 0px">Tag: <a href="http://hl7.org/fhir/R4/codesystem-common-tags.html">Actionable (Details: Common Tags code actionable = 'Actionable')</a></p></div><p><b>Carcinoma Staging</b>: STAGE_3A</p><p><b>Metastases</b>: None confirmed</p><p><b>Treatment Setting</b>: DAY_WARD</p><p><b>Cost Per Session</b>: 45000</p><p><b>identifier</b>: <code>https://nshr-uat.sha.go.ke/fhir/Identifier/claim-number</code>/CLAIM-ONC-001</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-type-cs institutional}">Institutional</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href="Patient-ECLM-PT-001.html">John Mwangi Kamau (official) Male, DoB: 1985-06-15 ( National ID: 12345678 (use: official, ))</a></p><p><b>billablePeriod</b>: 2025-11-15 --&gt; 2025-11-15</p><p><b>created</b>: 2025-11-10 11:00:00+0300</p><p><b>insurer</b>: <a href="Organization-ECLM-INS-001.html">Organization Social Health Authority</a></p><p><b>provider</b>: <a href="Organization-ECLM-ORG-001.html">Organization Nairobi General Hospital</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}">Provider</span></td></tr></table><h3>CareTeams</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td><td><b>Qualification</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><a href="Practitioner-ECLM-PRA-001.html">Practitioner Dr. James Ochieng (official)</a></td><td><span title="Codes:{https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-care-team-role-cs PRIMARY}">Primary provider</span></td><td><span title="Codes:{https://nshr-uat.sha.go.ke/fhir/CodeSystem/eclaims-provider-qualification-cs MD}">Doctor of Medicine</span></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{https://nshr-uat.sha.go.ke/fhir/CodeSystem/icd11-codes-cs 2C6Y}">Other specified malignant neoplasms of breast</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-ECLM-COV-001.html">Coverage: extension = Mobile Money,Active,General Practice; identifier = https://nshr-uat.sha.go.ke/fhir/Identifier/coverage-number#COV-SHA-2024-001234; status = active; type = Medical; relationship = Self; period = 2024-01-01 --&gt; 2024-12-31</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/ex-benefitcategory 1}">Medical Care</span></p><p><b>productOrService</b>: <span title="Codes:{https://nshr-uat.sha.go.ke/fhir/CodeSystem/KenyaSocialHealthAuthorityInterventionCS SHA-06}">Hematology and Oncology</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>45000</td><td>Kenyan shilling</td></tr></table><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>45000</td><td>Kenyan shilling</td></tr></table></blockquote></div>
  </text>
  <extension
             url="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-carcinoma-staging">
    <valueString value="STAGE_3A"/>
  </extension>
  <extension
             url="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-metastases">
    <valueString value="None confirmed"/>
  </extension>
  <extension
             url="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-treatment-setting">
    <valueString value="DAY_WARD"/>
  </extension>
  <extension
             url="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-cost-per-session">
    <valueString value="45000"/>
  </extension>
  <identifier>
    <system value="https://nshr-uat.sha.go.ke/fhir/Identifier/claim-number"/>
    <value value="CLAIM-ONC-001"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system
              value="https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-type-cs"/>
      <code value="institutional"/>
      <display value="Institutional"/>
    </coding>
  </type>
  <use value="preauthorization"/>
  <patient>🔗 
    <reference value="Patient/ECLM-PT-001"/>
  </patient>
  <billablePeriod>
    <start value="2025-11-15"/>
    <end value="2025-11-15"/>
  </billablePeriod>
  <created value="2025-11-10T11:00:00+03:00"/>
  <insurer>🔗 
    <reference value="Organization/ECLM-INS-001"/>
  </insurer>
  <provider>🔗 
    <reference value="Organization/ECLM-ORG-001"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
      <display value="Normal"/>
    </coding>
  </priority>
  <payee>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
      </coding>
    </type>
  </payee>
  <careTeam>
    <sequence value="1"/>
    <provider>🔗 
      <reference value="Practitioner/ECLM-PRA-001"/>
    </provider>
    <role>
      <coding>
        <system
                value="https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-care-team-role-cs"/>
        <code value="PRIMARY"/>
        <display value="Primary provider"/>
      </coding>
    </role>
    <qualification>
      <coding>
        <system
                value="https://nshr-uat.sha.go.ke/fhir/CodeSystem/eclaims-provider-qualification-cs"/>
        <code value="MD"/>
        <display value="Doctor of Medicine"/>
      </coding>
    </qualification>
  </careTeam>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system
                value="https://nshr-uat.sha.go.ke/fhir/CodeSystem/icd11-codes-cs"/>
        <code value="2C6Y"/>
        <display value="Other specified malignant neoplasms of breast"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/ECLM-COV-001"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <category>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory"/>
        <code value="1"/>
        <display value="Medical Care"/>
      </coding>
    </category>
    <productOrService>
      <coding>
        <system
                value="https://nshr-uat.sha.go.ke/fhir/CodeSystem/KenyaSocialHealthAuthorityInterventionCS"/>
        <code value="SHA-06"/>
        <display value="Hematology and Oncology"/>
      </coding>
    </productOrService>
    <quantity>
      <value value="1"/>
    </quantity>
    <unitPrice>
      <value value="45000"/>
      <currency value="KES"/>
    </unitPrice>
    <net>
      <value value="45000"/>
      <currency value="KES"/>
    </net>
  </item>
</Claim>