<?xml version="1.0" encoding="UTF-8"?>

<Claim xmlns="http://hl7.org/fhir">
  <id value="ECLM-OPT-001"/>
  <meta>
    <profile value="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/ke-eclaims-opticalpreauth"/>
    <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-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>
  </text>
  <extension url="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-lens-prescription">
    <valueString value="OD: SPH -2.50 CYL -0.50 AXIS 090; OS: SPH -2.00 CYL -0.25 AXIS 085"/>
  </extension>
  <extension url="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-replacement">
    <valueString value="New"/>
  </extension>
  <extension url="https://nshr-uat.sha.go.ke/fhir/StructureDefinition/eclaims-reason-for-service">
    <valueString value="Glasses — reduced visual acuity"/>
  </extension>
  <identifier>
    <system value="https://nshr-uat.sha.go.ke/fhir/Identifier/claim-number"/>
    <value value="CLAIM-OPT-001"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-type-cs"/>
      <code value="vision"/>
      <display value="Vision"/>
    </coding>
  </type>
  <use value="preauthorization"/>
  <patient>
    <reference value="Patient/ECLM-PT-001"/>
  </patient>
  <billablePeriod>
    <start value="2025-11-10"/>
    <end value="2025-11-10"/>
  </billablePeriod>
  <created value="2025-11-10T09:30:00+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="9C80.0"/>
        <display value="Myopia"/>
      </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-05"/>
        <display value="Eye Health"/>
      </coding>
    </productOrService>
    <quantity>
      <value value="1"/>
    </quantity>
    <unitPrice>
      <value value="7500"/>
      <currency value="KES"/>
    </unitPrice>
    <net>
      <value value="7500"/>
      <currency value="KES"/>
    </net>
  </item>
</Claim>