Kenya eClaims Implementation Guide
0.1.0 - ci-build Kenya flag

Kenya eClaims Implementation Guide, published by Digital Health Agency (DHA), 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 ClaimResponse - Sent Back - TTL Representation

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

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

<http://hl7.org/fhir/ClaimResponse/8e0e3d44-4b7a-47d6-8b82-39fa646f8088> a fhir:ClaimResponse ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "8e0e3d44-4b7a-47d6-8b82-39fa646f8088"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "https://fhir.dha.go.ke/ig/eclaims/StructureDefinition/ke-eclaims-claimresponse" ;
       fhir:index 0 ;
       fhir:link <https://fhir.dha.go.ke/ig/eclaims/StructureDefinition/ke-eclaims-claimresponse>
     ]
  ] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse 8e0e3d44-4b7a-47d6-8b82-39fa646f8088</b></p><a name=\"8e0e3d44-4b7a-47d6-8b82-39fa646f8088\"> </a><a name=\"hc8e0e3d44-4b7a-47d6-8b82-39fa646f8088\"> </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-claimresponse.html\">Kenya eClaims ClaimResponse Profile</a></p></div><p><b>Claim Workflow State</b>: <span title=\"Codes:{https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-state-cs sent-back}\">Sent Back</span></p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-example.html\">Jane Wanjiku  Female, DoB: 1985-06-15</a></p><p><b>created</b>: 2025-10-07 18:47:22+0000</p><p><b>insurer</b>: <a href=\"Organization-sha-insurer.html\">Social Health Authority</a></p><p><b>request</b>: <a href=\"Claim-ae044c1d-9ecb-4294-be9b-0702e7892596.html\">Claim: status = active; type = Institutional; use = claim; created = 2025-10-01; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication benefit}\">benefit</span></p><h3>Amounts</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>11200</td><td>Kenyan shilling</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Benefit Amount</span></p><h3>Amounts</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>11200</td><td>Kenyan shilling</td></tr></table></blockquote><blockquote><p><b>processNote</b></p><p><b>number</b>: 1</p><p><b>type</b>: Display</p><p><b>text</b>: medical cases</p></blockquote><blockquote><p><b>processNote</b></p><p><b>number</b>: 2</p><p><b>type</b>: Display</p><p><b>text</b>: For surveillance review</p></blockquote></div>"
  ] ;
  fhir:DomainResource.extension [
     fhir:index 0 ;
     fhir:Extension.url [ fhir:value "https://fhir.dha.go.ke/ig/eclaims/StructureDefinition/eclaim-state-extension" ] ;
     fhir:Extension.valueCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "https://nshr-uat.sha.go.ke/fhir/CodeSystem/claim-state-cs" ] ;
         fhir:Coding.code [ fhir:value "sent-back" ] ;
         fhir:Coding.display [ fhir:value "Sent Back" ]
       ]
     ]
  ] ;
  fhir:ClaimResponse.status [ fhir:value "active"] ;
  fhir:ClaimResponse.type [
     fhir:CodeableConcept.coding [
       fhir:index 0 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ] ;
       fhir:Coding.code [ fhir:value "institutional" ]
     ]
  ] ;
  fhir:ClaimResponse.use [ fhir:value "claim"] ;
  fhir:ClaimResponse.patient [
     fhir:link <http://hl7.org/fhir/Patient/example> ;
     fhir:Reference.reference [ fhir:value "Patient/example" ]
  ] ;
  fhir:ClaimResponse.created [ fhir:value "2025-10-07T18:47:22+00:00"^^xsd:dateTime] ;
  fhir:ClaimResponse.insurer [
     fhir:link <http://hl7.org/fhir/Organization/sha-insurer> ;
     fhir:Reference.reference [ fhir:value "Organization/sha-insurer" ] ;
     fhir:Reference.display [ fhir:value "Social Health Authority" ]
  ] ;
  fhir:ClaimResponse.request [
     fhir:link <http://hl7.org/fhir/Claim/ae044c1d-9ecb-4294-be9b-0702e7892596> ;
     fhir:Reference.reference [ fhir:value "Claim/ae044c1d-9ecb-4294-be9b-0702e7892596" ]
  ] ;
  fhir:ClaimResponse.outcome [ fhir:value "complete"] ;
  fhir:ClaimResponse.item [
     fhir:index 0 ;
     fhir:ClaimResponse.item.itemSequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0 ;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0 ;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ;
           fhir:Coding.code [ fhir:value "benefit" ] ;
           fhir:Coding.display [ fhir:value "Benefit Amount" ]
         ] ;
         fhir:CodeableConcept.text [ fhir:value "benefit" ]
       ] ;
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "11200"^^xsd:decimal ] ;
         fhir:Money.currency [ fhir:value "KES" ]
       ]
     ]
  ] ;
  fhir:ClaimResponse.total [
     fhir:index 0 ;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ;
         fhir:Coding.code [ fhir:value "benefit" ] ;
         fhir:Coding.display [ fhir:value "Benefit Amount" ]
       ]
     ] ;
     fhir:ClaimResponse.total.amount [
       fhir:Money.value [ fhir:value "11200"^^xsd:decimal ] ;
       fhir:Money.currency [ fhir:value "KES" ]
     ]
  ] ;
  fhir:ClaimResponse.processNote [
     fhir:index 0 ;
     fhir:ClaimResponse.processNote.number [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:ClaimResponse.processNote.type [ fhir:value "display" ] ;
     fhir:ClaimResponse.processNote.text [ fhir:value "medical cases" ]
  ], [
     fhir:index 1 ;
     fhir:ClaimResponse.processNote.number [ fhir:value "2"^^xsd:positiveInteger ] ;
     fhir:ClaimResponse.processNote.type [ fhir:value "display" ] ;
     fhir:ClaimResponse.processNote.text [ fhir:value "For surveillance review" ]
  ] .

<http://hl7.org/fhir/Patient/example> a fhir:Patient .

<http://hl7.org/fhir/Organization/sha-insurer> a fhir:Organization .

<http://hl7.org/fhir/Claim/ae044c1d-9ecb-4294-be9b-0702e7892596> a fhir:Claim .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/ClaimResponse/8e0e3d44-4b7a-47d6-8b82-39fa646f8088.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/ClaimResponse/8e0e3d44-4b7a-47d6-8b82-39fa646f8088.ttl> .