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

Table of Contents

.. 0 Table of Contents
... 1 Home
... 2 Background
... 3 Use Cases
... 4 Actors & Transactions
... 5 Security & Privacy
... 6 Conformance Requirements
... 7 Terminology Guidance
... 8 Downloads & Validation
... 9 Artifacts Summary
.... 9.1 Claim Response - Preauthorization
.... 9.2 Claim Submission
.... 9.3 Coverage Profile
.... 9.4 eClaims Condition/Diagnosis Profile
.... 9.5 eClaims Diagnostic Report Profile
.... 9.6 eClaims Encounter Profile
.... 9.7 eClaims Episode of Care Profile
.... 9.8 eClaims Medication Dispense Profile
.... 9.9 eClaims Medication Request Profile
.... 9.10 eClaims Medication Statement Profile
.... 9.11 eClaims Organization Profile
.... 9.12 eClaims Patient Profile
.... 9.13 eClaims Payment Notice Profile
.... 9.14 eClaims Practitioner Profile
.... 9.15 eClaims Provenance Profile
.... 9.16 Imaging Preauthorization
.... 9.17 Kenya eClaims Base Profile
.... 9.18 Kenya eClaims ClaimResponse Profile
.... 9.19 Oncology Preauthorization
.... 9.20 Optical Preauthorization
.... 9.21 Renal Preauthorization
.... 9.22 Surgical Preauthorization
.... 9.23 Anaesthesia Type
.... 9.24 Annual Limits Category Extension
.... 9.25 Attachment Type
.... 9.26 Carcinoma Staging
.... 9.27 Chief Complaint
.... 9.28 Claim Workflow State
.... 9.29 Clinical Indications
.... 9.30 Consultation Amount
.... 9.31 Cost Per Session
.... 9.32 Current member status Extension
.... 9.33 Exclusion Extension
.... 9.34 Eye Examination Amount
.... 9.35 Frame Amount
.... 9.36 Has Coinsurance
.... 9.37 History of Present Illness
.... 9.38 Investigations
.... 9.39 Item Coverage Reference
.... 9.40 Last Replacement Date
.... 9.41 Lens Amount
.... 9.42 Lens Prescription
.... 9.43 Metastases
.... 9.44 Other Metastases
.... 9.45 Patient Invoice Details
.... 9.46 Paymen tMethod Extension
.... 9.47 Physical Examination
.... 9.48 Plan Type Extension
.... 9.49 Preauthorization Expiry Date
.... 9.50 Preauthorization Expiry Date
.... 9.51 Preauthorization Expiry Date
.... 9.52 Preauthorization Token
.... 9.53 Provider Auth Token
.... 9.54 Raw Preauth Source Data
.... 9.55 Reason For Service
.... 9.56 Replacement Type
.... 9.57 Session Expected Date
.... 9.58 Treatment Setting
.... 9.59 Vital Signs
.... 9.60 Address Use ValueSet
.... 9.61 Administration Method ValueSet
.... 9.62 Administrative Gender ValueSet
.... 9.63 As Needed Reason ValueSet
.... 9.64 Attachment Type ValueSet
.... 9.65 Civil Status ValueSet
.... 9.66 Claim Care Team Role ValueSet
.... 9.67 Claim Diagnosis ValueSet
.... 9.68 Claim Status ValueSet
.... 9.69 Claim Subtype ValueSet
.... 9.70 Claim Type ValueSet
.... 9.71 Claim Use ValueSet
.... 9.72 ClaimResponse Adjudication Error ValueSet
.... 9.73 ClaimResponse Forms ValueSet
.... 9.74 ClaimResponse Funds Reserve ValueSet
.... 9.75 ClaimResponse Payee Type ValueSet
.... 9.76 Condition Category ValueSet
.... 9.77 Condition Clinical Status ValueSet
.... 9.78 Condition Codes ValueSet
.... 9.79 Condition Severity ValueSet
.... 9.80 Condition Verification Status ValueSet
.... 9.81 Contact Point System ValueSet
.... 9.82 Contact Point Use ValueSet
.... 9.83 Coverage Class ValueSet
.... 9.84 Coverage Exclusion Reason ValueSet
.... 9.85 Coverage Member Status ValueSet
.... 9.86 Coverage Plan Type ValueSet
.... 9.87 Coverage Type ValueSet
.... 9.88 Dosage Additional Instruction ValueSet
.... 9.89 Encounter Status ValueSet
.... 9.90 Episode of Care Status ValueSet
.... 9.91 Episode of Care Type ValueSet
.... 9.92 Gender ValueSet
.... 9.93 Generic Products ValueSet
.... 9.94 ICD ValueSet
.... 9.95 Identifier Types ValueSet
.... 9.96 Identifier Use ValueSet
.... 9.97 Kenya Institutional Body Site ValueSet
.... 9.98 Kenya Social Health Authority Interventions ValueSet
.... 9.99 Kenya Subsite ValueSet
.... 9.100 Medication Status Reason ValueSet
.... 9.101 Name Use ValueSet
.... 9.102 Payment Method ValueSet
.... 9.103 Preauthorization Exclusion Reason ValueSet
.... 9.104 Provider Qualification ValueSet
.... 9.105 Related Claim Relationship ValueSet
.... 9.106 Waiver Type ValueSet
.... 9.107 Address Use Code System
.... 9.108 Administration Method Code System
.... 9.109 Administrative Gender Code System
.... 9.110 As Needed Reason Code System
.... 9.111 Attachment Type Code System
.... 9.112 BodySite Code System
.... 9.113 Civil Status Code System
.... 9.114 Claim Care Team Role Code System
.... 9.115 Claim Expiry Code System
.... 9.116 Claim State Code System
.... 9.117 Claim Status Code System
.... 9.118 Claim Subtype Code System
.... 9.119 Claim Type Code System
.... 9.120 Claim Use Code System
.... 9.121 Condition Category Code System
.... 9.122 Condition Category Code System
.... 9.123 Condition Clinical Status Code System
.... 9.124 Condition Severity Code System
.... 9.125 Condition Verification Status Code System
.... 9.126 Contact Point System Code System
.... 9.127 Contact Point Use Code System
.... 9.128 Coverage Class Code System
.... 9.129 Coverage Member Status Code System
.... 9.130 Coverage Plan Type Code System
.... 9.131 Coverage Type Code System
.... 9.132 Dosage Additional Instruction Code System
.... 9.133 Encounter Status Code System
.... 9.134 Episode of Care Status Code System
.... 9.135 Episode of Care Type Code System
.... 9.136 Exclusion Code System
.... 9.137 Gender Code System
.... 9.138 Generic Products CodeSystem
.... 9.139 ICD-11 Code System
.... 9.140 Identifier Types Code System
.... 9.141 Identifier Use Code System
.... 9.142 Medication Status Reason Code System
.... 9.143 Name Use Code System
.... 9.144 Payment Method Code System
.... 9.145 PreAuthExclusions Code System
.... 9.146 Provider Qualification Code System
.... 9.147 Related Claim Relationship Code System
.... 9.148 Subsite Code System
.... 9.149 Subsite Code System
.... 9.150 Waiver Type Code System
.... 9.151 Example Claim for ClaimResponse (canceled)
.... 9.152 Example Claim for ClaimResponse (sent-back)
.... 9.153 Example Claim Response
.... 9.154 Example Claim Submission
.... 9.155 Example ClaimResponse - Canceled
.... 9.156 Example ClaimResponse - Sent Back
.... 9.157 Example Coverage
.... 9.158 Example eClaims Condition
.... 9.159 Example eClaims Coverage
.... 9.160 Example eClaims Diagnostic Report
.... 9.161 Example eClaims Encounter
.... 9.162 Example eClaims Episode of Care
.... 9.163 Example eClaims Insurer Organization
.... 9.164 Example eClaims Medication Dispense
.... 9.165 Example eClaims Medication Request
.... 9.166 Example eClaims Medication Statement
.... 9.167 Example eClaims Patient
.... 9.168 Example eClaims Payment Notice
.... 9.169 Example eClaims Practitioner
.... 9.170 Example eClaims Provider Organization
.... 9.171 Example Imaging Preauthorization
.... 9.172 Example Insurer Organization
.... 9.173 Example Kenya Claim Base
.... 9.174 Example Location
.... 9.175 Example Medication Request
.... 9.176 Example Oncology Preauthorization
.... 9.177 Example Optical Preauthorization
.... 9.178 Example Patient
.... 9.179 Example Patient (generic)
.... 9.180 Example Practitioner
.... 9.181 Example Provenance - Claim Submission
.... 9.182 Example Provider Organization
.... 9.183 Example Related Claim
.... 9.184 Example Renal Preauthorization
.... 9.185 Example Service Request
.... 9.186 Example Surgical Preauthorization
.... 9.187 Social Health Authority
.... 9.188 Stub Observation for DiagnosticReport
.... 9.189 Stub PaymentReconciliation for PaymentNotice