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 Optical Preauthorization - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Claim ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "ECLM-OPT-001"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "https://nshr-uat.sha.go.ke/fhir/StructureDefinition/ke-eclaims-opticalpreauth"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/StructureDefinition/ke-eclaims-opticalpreauth>     ] ) ;
    ( fhir:tag [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/common-tags"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/common-tags>       ] ;
fhir:code [ fhir:v "actionable" ] ;
fhir:display [ fhir:v "Actionable" ]     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim ECLM-OPT-001</b></p><a name=\"ECLM-OPT-001\"> </a><a name=\"hcECLM-OPT-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-opticalpreauth.html\">Optical 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>Lens Prescription</b>: OD: SPH -2.50 CYL -0.50 AXIS 090; OS: SPH -2.00 CYL -0.25 AXIS 085</p><p><b>Replacement Type</b>: New</p><p><b>Reason For Service</b>: Glasses — reduced visual acuity</p><p><b>identifier</b>: <code>https://nshr-uat.sha.go.ke/fhir/Identifier/claim-number</code>/CLAIM-OPT-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 vision}\">Vision</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>: 2025-11-10 --&gt; 2025-11-10</p><p><b>created</b>: 2025-11-10 09:30:00+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 9C80.0}\">Myopia</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-05}\">Eye Health</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>7500</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>7500</td><td>Kenyan shilling</td></tr></table></blockquote></div>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:extension ( [
fhir:url [
fhir:v "https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-lens-prescription"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-lens-prescription>     ] ;
fhir:value [
a fhir:String ;
fhir:v "OD: SPH -2.50 CYL -0.50 AXIS 090; OS: SPH -2.00 CYL -0.25 AXIS 085"     ]
  ] [
fhir:url [
fhir:v "https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-replacement"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-replacement>     ] ;
fhir:value [
a fhir:String ;
fhir:v "New"     ]
  ] [
fhir:url [
fhir:v "https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-reason-for-service"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-reason-for-service>     ] ;
fhir:value [
a fhir:String ;
fhir:v "Glasses — reduced visual acuity"     ]
  ] ) ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "https://nshr-uat.sha.go.ke/fhir/Identifier/claim-number"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/Identifier/claim-number>     ] ;
fhir:value [ fhir:v "CLAIM-OPT-001" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [
fhir:v "https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-type-cs"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-type-cs>       ] ;
fhir:code [ fhir:v "vision" ] ;
fhir:display [ fhir:v "Vision" ]     ] )
  ] ; # 
  fhir:use [ fhir:v "preauthorization"] ; # 
  fhir:patient [
fhir:l fhir:Patient/ECLM-PT-001 ;
fhir:reference [ fhir:v "Patient/ECLM-PT-001" ]
  ] ; # 
  fhir:billablePeriod [
fhir:start [ fhir:v "2025-11-10"^^xsd:date ] ;
fhir:end [ fhir:v "2025-11-10"^^xsd:date ]
  ] ; # 
  fhir:created [ fhir:v "2025-11-10T09:30:00+03:00"^^xsd:dateTime] ; # 
  fhir:insurer [
fhir:l fhir:Organization/ECLM-INS-001 ;
fhir:reference [ fhir:v "Organization/ECLM-INS-001" ]
  ] ; # 
  fhir:provider [
fhir:l fhir:Organization/ECLM-ORG-001 ;
fhir:reference [ fhir:v "Organization/ECLM-ORG-001" ]
  ] ; # 
  fhir:priority [
    ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/processpriority>       ] ;
fhir:code [ fhir:v "normal" ] ;
fhir:display [ fhir:v "Normal" ]     ] )
  ] ; # 
  fhir:payee [
fhir:type [
      ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/payeetype>         ] ;
fhir:code [ fhir:v "provider" ] ;
fhir:display [ fhir:v "Provider" ]       ] )     ]
  ] ; # 
  fhir:careTeam ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:provider [
fhir:l fhir:Practitioner/ECLM-PRA-001 ;
fhir:reference [ fhir:v "Practitioner/ECLM-PRA-001" ]     ] ;
fhir:role [
      ( fhir:coding [
fhir:system [
fhir:v "https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-care-team-role-cs"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-care-team-role-cs>         ] ;
fhir:code [ fhir:v "PRIMARY" ] ;
fhir:display [ fhir:v "Primary provider" ]       ] )     ] ;
fhir:qualification [
      ( fhir:coding [
fhir:system [
fhir:v "https://nshr-uat.sha.go.ke/fhir/CodeSystem/eclaims-provider-qualification-cs"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/CodeSystem/eclaims-provider-qualification-cs>         ] ;
fhir:code [ fhir:v "MD" ] ;
fhir:display [ fhir:v "Doctor of Medicine" ]       ] )     ]
  ] ) ; # 
  fhir:diagnosis ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [
fhir:v "https://nshr-uat.sha.go.ke/fhir/CodeSystem/icd11-codes-cs"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/CodeSystem/icd11-codes-cs>         ] ;
fhir:code [ fhir:v "9C80.0" ] ;
fhir:display [ fhir:v "Myopia" ]       ] )     ]
  ] ) ; # 
  fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v true ] ;
fhir:coverage [
fhir:l fhir:Coverage/ECLM-COV-001 ;
fhir:reference [ fhir:v "Coverage/ECLM-COV-001" ]     ]
  ] ) ; # 
  fhir:item ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    ( fhir:careTeamSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:category [
      ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/ex-benefitcategory"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/ex-benefitcategory>         ] ;
fhir:code [ fhir:v "1" ] ;
fhir:display [ fhir:v "Medical Care" ]       ] )     ] ;
fhir:productOrService [
      ( fhir:coding [
fhir:system [
fhir:v "https://nshr-uat.sha.go.ke/fhir/CodeSystem/KenyaSocialHealthAuthorityInterventionCS"^^xsd:anyURI ;
fhir:l <https://nshr-uat.sha.go.ke/fhir/CodeSystem/KenyaSocialHealthAuthorityInterventionCS>         ] ;
fhir:code [ fhir:v "SHA-05" ] ;
fhir:display [ fhir:v "Eye Health" ]       ] )     ] ;
fhir:quantity [
fhir:value [ fhir:v "1"^^xsd:decimal ]     ] ;
fhir:unitPrice [
fhir:value [ fhir:v "7500"^^xsd:decimal ] ;
fhir:currency [ fhir:v "KES" ]     ] ;
fhir:net [
fhir:value [ fhir:v "7500"^^xsd:decimal ] ;
fhir:currency [ fhir:v "KES" ]     ]
  ] ) . #