Kenya eClaims FHIR IG
0.1.0 - ci-build
Kenya eClaims FHIR IG
0.1.0 - ci-build
Kenya eClaims FHIR IG, published by iclKenya. 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
Contents:
This page provides a list of the FHIR artifacts defined as part of this implementation guide.
These define constraints on FHIR resources for systems conforming to this implementation guide.
| Claim Response - Preauthorization |
This profile defines constraints on the Claim resource for use within the Kenya eClaims Implementation Guide. It supports institutional claims with detailed clinical, financial, insurance, and adjudication metadata. |
| Claim Submission |
This is the final request for payment sent after services are delivered. |
| Coverage Profile |
This profile defines constraints on the Coverage resource for use within the Kenya eClaims Implementation Guide. It represents insurance coverage for a patient under a specific insurance scheme, including SHA and specialised schemes such as POMF and POMF_TEACHERS. |
| Imaging Preauthorization |
This profile is for authorizing high-cost Diagnostic Imaging. |
| Kenya eClaims Base Profile |
This is the foundation for all Financial Claims and Preauthorizations in Kenya. It enforces standard identifiers, actor references (Patient, Provider) and common extensions used across the entire eClaims ecosystem. |
| Kenya eClaims ClaimResponse Profile |
Profile for the response to a Claim or Preauthorization, including specific adjudication states and expiry logic. |
| Oncology Preauthorization |
This profile is for authorizing Cancer Treatment. |
| Optical Preauthorization |
This profile is for Optical Services. |
| Renal Preauthorization |
This profile is for requesting authorization for renal dialysis sessions. |
| Surgical Preauthorization |
This profile covers invasive procedures requiring a theatre or sterile setting. |
These define constraints on FHIR data types for systems conforming to this implementation guide.
| Anaesthesia Type |
Type of anaesthesia to be used (e.g. 'General', 'Local'). |
| Attachment Type |
Classifies the attachment (e.g. Discharge Summary, Final Bill). |
| Carcinoma Staging |
Stage of the carcinoma (e.g. 'STAGE_3'). |
| Chief Complaint |
The patient's primary complaint. |
| Claim Workflow State |
Tracks the specific state of the claim (e.g., Sent Back, Approved, surveillance). |
| Clinical Indications |
Clinical reasoning or specific indications for the procedure (e.g., 'End Stage Renal Disease'). |
| Consultation Amount | |
| Cost Per Session |
The cost per chemotherapy/radiotherapy session. |
| Eye Examination Amount | |
| Frame Amount | |
| Has Coinsurance |
Indicates if the patient has a coinsurance liability. |
| History of Present Illness |
Detailed history of the present illness. |
| Investigations |
List of investigations performed or requested (e.g. specific lab tests or imaging modalities). |
| Item Coverage Reference |
Link to the specific coverage/scheme applicable to this line item. |
| Last Replacement Date |
Date when the item was last replaced (for eligibility checks). |
| Lens Amount | |
| Lens Prescription |
Details of the lens prescription (Sphere, Cylinder, Axis). |
| Metastases |
Details on metastases (e.g. 'None', 'Bone', 'Liver'). |
| Other Metastases | |
| Patient Invoice Details |
Details regarding the provider's invoice and patient liability. |
| Physical Examination |
Findings from the physical examination. |
| Preauthorization Expiry Date |
Indicates when the approved preauthorization expires. |
| Preauthorization Token |
The specific unique token generated for this preauthorization request. |
| Provider Auth Token |
The authorization token issued to the provider for this session. |
| Raw Preauth Source Data |
Container for the full legacy JSON payload. |
| Reason For Service |
The reason for the optical service (e.g., 'Glasses'). |
| Replacement Type |
Indicates if this item is 'New' or a 'Replacement'. |
| Session Expected Date |
The expected date for the dialysis or therapy session. |
| Treatment Setting |
Setting where treatment is provided (e.g. 'DAY_WARD', 'INPATIENT'). |
| Vital Signs |
Recorded vital signs (e.g. Temperature, BP). |
These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.
| Example Claim Response |
An example Claim Response resource for Kenya eClaims Preauthorization, fully populated for testing. |
| Example ClaimResponse - Canceled |
An example of a Preauthorization that was canceled by request. |
| Example ClaimResponse - Sent Back |
An example of a ClaimResponse returned to the provider for surveillance review. |
| Example SHA Coverage |
An example insurance coverage for a patient under the SHA scheme. |