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.

This is the final request for payment sent after services are delivered.

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.

This profile is for authorizing high-cost Diagnostic Imaging.

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.

Profile for the response to a Claim or Preauthorization, including specific adjudication states and expiry logic.

This profile is for authorizing Cancer Treatment.

This profile is for Optical Services.

This profile is for requesting authorization for renal dialysis sessions.

This profile covers invasive procedures requiring a theatre or sterile setting.

This profile defines constraints on the Condition resource for use within the Kenya eClaims Implementation Guide. It represents a clinical diagnosis or problem associated with a patient's healthcare encounter.

This profile defines constraints on the DiagnosticReport resource for use within the Kenya eClaims Implementation Guide. It represents findings from diagnostic tests (lab, radiology, pathology) associated with a claim.

This profile defines constraints on the Encounter resource for use within the Kenya eClaims Implementation Guide. It captures the healthcare interaction during which services are rendered and claims are generated.

This profile defines constraints on the EpisodeOfCare resource for use within the Kenya eClaims Implementation Guide. It groups a set of related encounters and activities for a patient within a specific care program.

This profile defines constraints on the MedicationDispense resource for use within the Kenya eClaims Implementation Guide. It represents the dispensing of a medication to a patient.

This profile defines constraints on the MedicationRequest resource for use within the Kenya eClaims Implementation Guide. It represents a prescription or order for a medication for a patient.

This profile defines constraints on the MedicationStatement resource for use within the Kenya eClaims Implementation Guide. It records information about a medication being taken by a patient.

This profile defines constraints on the Organization resource for use within the Kenya eClaims Implementation Guide. It represents healthcare providers, insurers, and other organizations involved in claim processing.

This profile defines constraints on the Patient resource for use within the Kenya eClaims Implementation Guide. It represents a patient receiving healthcare services under the national insurance scheme.

This profile defines constraints on the PaymentNotice resource for use within the Kenya eClaims Implementation Guide. It provides notice of a payment-related event, such as the issuance or receipt of funds for a healthcare claim, supporting financial reconciliation and tracking.

This profile defines constraints on the Practitioner resource for use within the Kenya eClaims Implementation Guide. It represents a healthcare professional involved in claim processing or service delivery.

This profile defines constraints on the Provenance resource for use within the Kenya eClaims Implementation Guide. It tracks the origin, authorship, and handling of claims, preauthorizations, and related clinical resources submitted to the Social Health Authority.

Type of anaesthesia to be used (e.g. 'General', 'Local').

The category of service to which the limit applies.

Classifies the attachment (e.g. Discharge Summary, Final Bill).

Stage of the carcinoma (e.g. 'STAGE_3').

The patient's primary complaint.

Tracks the specific state of the claim (e.g., Sent Back, Approved, surveillance).

Clinical reasoning or specific indications for the procedure (e.g., 'End Stage Renal Disease').

The amount charged for the optical consultation service.

The cost per chemotherapy/radiotherapy session.

Current member status

A list of services or conditions that are explicitly not covered by this plan.

The amount charged for the eye examination service.

The amount charged for spectacle frames.

Indicates if the patient has a coinsurance liability.

Detailed history of the present illness.

List of investigations performed or requested (e.g. specific lab tests or imaging modalities).

Link to the specific coverage/scheme applicable to this line item.

Date when the item was last replaced (for eligibility checks).

The amount charged for spectacle lenses.

Details of the lens prescription (Sphere, Cylinder, Axis).

Details on metastases (e.g. 'None', 'Bone', 'Liver').

Details on additional metastases not captured in the main metastases field.

Details regarding the provider's invoice and patient liability.

The preferred method of payment for the beneficiary's share (e.g., credit card, direct debit).

Findings from the physical examination.

The specific type of plan

Indicates when the approved preauthorization expires.

Services excluded from preauthorization.

Indicates when the approved preauthorization expires.

The specific unique token generated for this preauthorization request.

The authorization token issued to the provider for this session.

Container for the full legacy JSON payload.

The reason for the optical service (e.g., 'Glasses').

Indicates if this item is 'New' or a 'Replacement'.

The expected date for the dialysis or therapy session.

Setting where treatment is provided (e.g. 'DAY_WARD', 'INPATIENT').

Recorded vital signs (e.g. Temperature, BP).

ValueSet for address use codes (MOH-Kenya OCL: ADDRESS-USE)

ValueSet for medication administration methods (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/administration-method-codes)

ValueSet for administrative gender codes (MOH-Kenya OCL: ADMINISTRATIVE-GENDER)

ValueSet for conditions that trigger as-needed medication use (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/medication-as-needed-reason)

ValueSet for types of attachments submitted with a claim in Kenya eClaims.

ValueSet for civil/marital status codes (MOH-Kenya OCL: CIVIL-STATUS)

ValueSet for the role of a care team member in a claim (MOH-Kenya OCL: CLAIM-CARE-TEAM-ROLE)

ValueSet for diagnosis codes used in Kenya eClaims. Includes both Kenya-defined ICD-11 category codes and the local ICD-11 MMS code system for individual clinical diagnoses.

ValueSet for claim status codes (MOH-Kenya OCL: CLAIM-STATUS)

ValueSet for claim subtype codes (MOH-Kenya OCL: CLAIM-SUBTYPE)

ValueSet for claim type codes (MOH-Kenya OCL: CLAIM-TYPE)

ValueSet for intended use of a claim (MOH-Kenya OCL: CLAIM-USE)

Non-experimental wrapper for adjudication error codes returned in a ClaimResponse.

Non-experimental wrapper for printed or electronic form identifiers used with ClaimResponse.

Non-experimental wrapper for funds reserve codes indicating to whom excess funds belong.

Non-experimental wrapper for payee type codes used in ClaimResponse adjudication.

ValueSet for condition category codes (MOH-Kenya OCL: CONDITION-CATEGORY)

ValueSet for condition clinical status codes (MOH-Kenya OCL: CONDITION-CLINICAL-STATUS)

Codes for clinical conditions and diagnoses. References ICD-10 pending population of the MOH-KENYA CONDITION-CODES OCL collection.

ValueSet for the clinical severity of a condition (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/condition-severity)

ValueSet for condition verification status codes (MOH-Kenya OCL: CONDITION-VERIFICATION-STATUS)

ValueSet for contact point system codes (MOH-Kenya OCL: CONTACT-POINT-SYSTEM)

ValueSet for contact point use codes (MOH-Kenya OCL: CONTACT-POINT-USE)

ValueSet for insurance coverage class codes (MOH-Kenya OCL: COVERAGE-CLASS)

ValueSet for reasons a service is excluded from coverage in Kenya health insurance (MOH-Kenya OCL: COVERAGE-EXCLUSION-REASON)

ValueSet for the status of a coverage member (MOH-Kenya OCL: COVERAGE-MEMBER-STATUS)

ValueSet for coverage plan type codes (MOH-Kenya OCL: COVERAGE-PLAN-TYPE)

ValueSet for insurance coverage type codes (MOH-Kenya OCL: COVERAGE-TYPE)

ValueSet for additional dosage/dispensing instructions (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/additional-instruction-codes)

ValueSet for encounter status codes (MOH-Kenya OCL: ENCOUNTER-STATUS)

ValueSet for episode of care status codes (MOH-Kenya OCL: EPISODE-OF-CARE-STATUS)

ValueSet for episode of care type codes (MOH-Kenya OCL: EPISODE-OF-CARE-TYPE)

ValueSet for extended gender codes in Kenya (MOH-Kenya OCL: GENDER)

ValueSet for generic pharmaceutical products (MOH-Kenya: GenericProducts)

ValueSet for ICD codes used in Kenya eClaims.

ValueSet for identifier type codes used in Kenya (MOH-Kenya OCL: IDENTIFIER-TYPES)

ValueSet for identifier use codes (MOH-Kenya OCL: IDENTIFIER-USE)

ValueSet for body site codes used in Kenya institutional claims (MOH-Kenya OCL: INSTITUTIONAL-BODY-SITE)

ValueSet for interventions approved by the Kenya Social Health Authority (MOH-Kenya OCL: KenyaSocialHealthAuthorityInterventions)

ValueSet for sub-site codes used in Kenya claims (MOH-Kenya OCL: SUBSITE)

ValueSet for reasons a medication was stopped or paused (local replacement for SNOMED CT-based http://hl7.org/fhir/ValueSet/reason-medication-status-codes)

ValueSet for name use codes (MOH-Kenya OCL: NAME-USE)

ValueSet for payment method codes (MOH-Kenya OCL: PAYMENT-METHOD)

ValueSet for reasons a service may be excluded from preauthorization in Kenya (MOH-Kenya OCL: PREAUTH-EXCLUSION-REASON)

Qualification and credential codes for healthcare providers in Kenya eClaims, drawn from the local ProviderQualificationCS.

ValueSet for related claim relationship codes (MOH-Kenya OCL: RELATED-CLAIM-RELATIONSHIP)

ValueSet for types of waivers applicable in Kenya health insurance claims (MOH-Kenya OCL: WAIVER-TYPE)

Codes for the use of an address. Codes align with FHIR address-use to allow required binding as a subset.

Codes for the method of medication administration, replacing SNOMED CT-based HL7 ValueSet

Codes for administrative gender. Codes align with FHIR administrative-gender to allow required binding as a subset.

Codes for the condition that triggers as-needed medication use, replacing SNOMED CT-based HL7 ValueSet

Codes classifying the type of attachment submitted with a claim (e.g. Discharge Summary, Final Bill).

A code system that defines categories for Institutional Body Sites

Codes for civil/marital status (MOH-Kenya OCL: CIVIL-STATUS)

Codes for the role of a care team member in a claim (MOH-Kenya OCL: CLAIM-CARE-TEAM-ROLE)

Codes for claim or preauthorization expiry types in Kenya eClaims.

Codes for the specific workflow state of a claim in Kenya eClaims.

Codes for the status of a claim. Codes align with FHIR fm-status to allow required binding as a subset.

Kenya-specific codes for the subtype of claim (MOH-Kenya OCL: CLAIM-SUBTYPE).

Codes for the type of claim. Codes align with FHIR claim-type to allow required binding as a subset.

Codes for the intended use of a claim. Codes align with FHIR claim-use to allow required binding as a subset.

A code system that defines categories for Social Health Authority Interventions

Codes for the category of a condition (MOH-Kenya OCL: CONDITION-CATEGORY)

Codes for the clinical status of a condition. Codes align with FHIR condition-clinical to allow required binding as a subset.

Codes for the clinical severity of a condition, replacing SNOMED CT-based HL7 ValueSet

Codes for the verification status of a condition. Codes align with FHIR condition-ver-status to allow required binding as a subset.

Codes for contact point systems. Codes align with FHIR contact-point-system to allow required binding as a subset.

Codes for contact point use. Codes align with FHIR contact-point-use to allow required binding as a subset.

Codes for insurance coverage class categories (MOH-Kenya OCL: COVERAGE-CLASS)

Codes for the status of a coverage member (MOH-Kenya OCL: COVERAGE-MEMBER-STATUS)

Codes for types of coverage plan (MOH-Kenya OCL: COVERAGE-PLAN-TYPE)

Codes for the type of insurance coverage (MOH-Kenya OCL: COVERAGE-TYPE)

Codes for additional dispensing/dosage instructions, replacing SNOMED CT-based HL7 ValueSet

Codes for the status of an encounter. Codes align with FHIR encounter-status to allow required binding as a subset.

Codes for the status of an episode of care. Codes align with FHIR episode-of-care-status to allow required binding as a subset.

Codes for the type of episode of care (MOH-Kenya OCL: EPISODE-OF-CARE-TYPE)

A code system that defines Exclusion

Extended gender identity codes for Kenya (MOH-Kenya OCL: GENDER). Extends beyond FHIR administrative-gender with additional local codes.

Generic medicinal product codes from MOH PPB OCL.

ICD-11 codes for mortality and morbidity statistics. Source: MOH-KENYA OCL ICD-11-FOR-MORTALITY-AND-MORBIDITY-STATISTICS.

Codes for types of identifiers used in Kenya (MOH-Kenya OCL: IDENTIFIER-TYPES)

Codes for the use of an identifier. Codes align with FHIR identifier-use to allow required binding as a subset.

Codes for the reason a medication was stopped or paused, replacing SNOMED CT-based HL7 ValueSet

Codes for the use of a name. Codes align with FHIR name-use to allow required binding as a subset.

Codes for payment methods (MOH-Kenya OCL: PAYMENT-METHOD)

A code system that defines PreAuth Exclusions

Qualification and credential codes for healthcare providers in Kenya eClaims. Codes align with HL7 v2 Table 0360 to ensure interoperability.

Codes for the relationship between related claims (MOH-Kenya OCL: RELATED-CLAIM-RELATIONSHIP)

A code system that defines Subsite

A code system that defines Subsite

A code system that defines Waiver Type

An example Claim Response resource for Kenya eClaims Preauthorization, fully populated for testing.

An example Claim conforming to KenyaClaimSubmission for final payment after inpatient services.

Stub claim used as a reference target in the ClaimResponseCanceledExample.

Stub claim used as a reference target in the ClaimResponseSentBackExample.

An example of a Preauthorization that was canceled by request.

An example of a ClaimResponse returned to the provider for surveillance review.

Stub coverage used as a reference target in claim examples.

An example Claim conforming to KenyaImagingPreauth for MRI of the right femur.

Stub insurer organization used as a reference target in claim examples.

An example Claim conforming to the KenyaClaimBase profile.

Stub location used as a reference target in claim examples.

Stub medication request used as a reference target in claim examples.

An example Claim conforming to KenyaOncologyPreauth for a chemotherapy session.

An example Claim conforming to KenyaOpticalPreauth for prescription eyeglasses.

Stub patient instance used as a reference target in claim examples.

Stub patient instance used as a reference target in claim response examples.

Stub practitioner used as a reference target in claim examples.

An example of a Provenance record tracking the submission of an institutional claim to the Social Health Authority by a healthcare provider.

Stub provider organization used as a reference target in claim examples.

Stub related claim used as a reference target in claim examples.

An example Claim conforming to KenyaRenalPreauth for a haemodialysis session.

Stub service request used as a reference target in claim examples.

An example Claim conforming to KenyaSurgicalPreauth for an appendicectomy.

An example Condition resource conforming to EClaimsCondition.

An example Coverage resource conforming to EclaimsCoverage.

An example DiagnosticReport conforming to EClaimsDiagnosticReport.

An example Encounter resource conforming to EClaimsEncounter.

An example EpisodeOfCare resource conforming to EClaimsEpisodeOfCare.

An example Social Health Authority insurer Organization conforming to EClaimsOrganization.

An example MedicationDispense conforming to EClaimsMedicationDispense.

An example MedicationRequest conforming to EClaimsMedicationRequest.

An example MedicationStatement conforming to EClaimsMedicationStatement.

An example Patient resource conforming to the EClaimsPatient profile.

An example PaymentNotice conforming to EClaimsPaymentNotice.

An example Practitioner resource conforming to EClaimsPractitioner.

An example healthcare provider Organization conforming to EClaimsOrganization.

Stub SHA insurer organization used as a reference target in claim response examples.

A minimal stub Observation referenced by the DiagnosticReport example.

A minimal stub PaymentReconciliation referenced by the PaymentNotice example.