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

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 Diagnostic Report Codes ValueSet
.... 9.89 Dosage Additional Instruction ValueSet
.... 9.90 Encounter Status ValueSet
.... 9.91 Episode of Care Status ValueSet
.... 9.92 Episode of Care Type ValueSet
.... 9.93 Gender ValueSet
.... 9.94 Generic Products ValueSet
.... 9.95 ICD ValueSet
.... 9.96 Identifier Types ValueSet
.... 9.97 Identifier Use ValueSet
.... 9.98 Kenya Institutional Body Site ValueSet
.... 9.99 Kenya Social Health Authority Interventions ValueSet
.... 9.100 Kenya Subsite ValueSet
.... 9.101 Medication Status Reason ValueSet
.... 9.102 Name Use ValueSet
.... 9.103 Payment Method ValueSet
.... 9.104 Preauthorization Exclusion Reason ValueSet
.... 9.105 Provider Qualification ValueSet
.... 9.106 Related Claim Relationship ValueSet
.... 9.107 Waiver Type ValueSet
.... 9.108 Address Use Code System
.... 9.109 Administration Method Code System
.... 9.110 Administrative Gender Code System
.... 9.111 As Needed Reason Code System
.... 9.112 Attachment Type Code System
.... 9.113 BodySite Code System
.... 9.114 Civil Status Code System
.... 9.115 Claim Care Team Role Code System
.... 9.116 Claim Expiry Code System
.... 9.117 Claim State Code System
.... 9.118 Claim Status Code System
.... 9.119 Claim Subtype Code System
.... 9.120 Claim Type Code System
.... 9.121 Claim Use Code System
.... 9.122 Condition Category Code System
.... 9.123 Condition Category Code System
.... 9.124 Condition Clinical Status Code System
.... 9.125 Condition Severity Code System
.... 9.126 Condition Verification Status Code System
.... 9.127 Contact Point System Code System
.... 9.128 Contact Point Use Code System
.... 9.129 Coverage Class Code System
.... 9.130 Coverage Member Status Code System
.... 9.131 Coverage Plan Type Code System
.... 9.132 Coverage Type Code System
.... 9.133 Diagnostic Report Codes Code System
.... 9.134 Dosage Additional Instruction Code System
.... 9.135 Encounter Status Code System
.... 9.136 Episode of Care Status Code System
.... 9.137 Episode of Care Type Code System
.... 9.138 Exclusion Code System
.... 9.139 Gender Code System
.... 9.140 Generic Products CodeSystem
.... 9.141 ICD-11 Code System
.... 9.142 Identifier Types Code System
.... 9.143 Identifier Use Code System
.... 9.144 Medication Status Reason Code System
.... 9.145 Name Use Code System
.... 9.146 Payment Method Code System
.... 9.147 PreAuthExclusions Code System
.... 9.148 Provider Qualification Code System
.... 9.149 Related Claim Relationship Code System
.... 9.150 Subsite Code System
.... 9.151 Subsite Code System
.... 9.152 Waiver Type Code System
.... 9.153 Example Claim for ClaimResponse (canceled)
.... 9.154 Example Claim for ClaimResponse (sent-back)
.... 9.155 Example Claim Response
.... 9.156 Example Claim Submission
.... 9.157 Example ClaimResponse - Canceled
.... 9.158 Example ClaimResponse - Sent Back
.... 9.159 Example Coverage
.... 9.160 Example eClaims Condition
.... 9.161 Example eClaims Coverage
.... 9.162 Example eClaims Diagnostic Report
.... 9.163 Example eClaims Encounter
.... 9.164 Example eClaims Episode of Care
.... 9.165 Example eClaims Insurer Organization
.... 9.166 Example eClaims Medication Dispense
.... 9.167 Example eClaims Medication Request
.... 9.168 Example eClaims Medication Statement
.... 9.169 Example eClaims Patient
.... 9.170 Example eClaims Payment Notice
.... 9.171 Example eClaims Practitioner
.... 9.172 Example eClaims Provider Organization
.... 9.173 Example Imaging Preauthorization
.... 9.174 Example Insurer Organization
.... 9.175 Example Kenya Claim Base
.... 9.176 Example Location
.... 9.177 Example Medication Request
.... 9.178 Example Oncology Preauthorization
.... 9.179 Example Optical Preauthorization
.... 9.180 Example Patient
.... 9.181 Example Patient (generic)
.... 9.182 Example Practitioner
.... 9.183 Example Provenance - Claim Submission
.... 9.184 Example Provider Organization
.... 9.185 Example Related Claim
.... 9.186 Example Renal Preauthorization
.... 9.187 Example Service Request
.... 9.188 Example Surgical Preauthorization
.... 9.189 Social Health Authority
.... 9.190 Stub Observation for DiagnosticReport
.... 9.191 Stub PaymentReconciliation for PaymentNotice