SIL HIE Implementation Guide, published by Kathurima Kimathi. 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/savannahghi/hie-fhir-ig-profile/ and changes regularly. See the Directory of published versions

• Narrative Content
• XML
• JSON
• TTL

: Example HIE ClaimResponse - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="HIEClaimResponse-example"/>
  <meta>
    <profile
             value="https://nshr.dha.go.ke/fhir/StructureDefinition/hie-claimresponse"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>ClaimResponse Summary</b></p><p>Outcome complete. Primary coverage approved with member copay. Payment issued.</p><table><thead><tr><th align="left">Header</th><th align="left">Value</th></tr></thead><tbody><tr><td>Status</td><td>active</td></tr><tr><td>Use</td><td>claim</td></tr><tr><td>Outcome</td><td>complete</td></tr><tr><td>Patient</td><td>Jane Patient</td></tr><tr><td>Insurer</td><td>Acme Health Insurance</td></tr><tr><td>Request</td><td>Claim/claim-001</td></tr><tr><td>Created</td><td>2025-11-15</td></tr></tbody></table><p><b>Item Adjudication</b></p><table><thead><tr><th align="left">ItemSeq</th><th align="left">Category</th><th align="left">Reason</th><th align="left">Amount</th></tr></thead><tbody><tr><td>1</td><td>eligible</td><td/><td>100.00 USD</td></tr><tr><td>1</td><td>copay</td><td/><td>20.00 USD</td></tr><tr><td>1</td><td>benefit</td><td/><td>80.00 USD</td></tr></tbody></table><p><b>Totals</b></p><ul><li>Submitted: 100.00 USD</li><li>Copay: 20.00 USD</li><li>Benefit: 80.00 USD</li></ul><p><b>Payment</b></p><ul><li>Type: payment</li><li>Date: 2025-11-16</li><li>Amount: 80.00 USD</li><li>Reference: EPI-778899</li></ul><p><b>Notes</b></p><ul><li>Approved per plan. Member copay applied.</li></ul></div>
  </text>
  <identifier>
    <use value="official"/>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="ACSN"/>
        <display value="Accession ID"/>
      </coding>
    </type>
    <system value="http://payer.example.org/claimresponses"/>
    <value value="CR-2025-0001"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="professional"/>
      <display value="Professional"/>
    </coding>
  </type>
  <use value="claim"/>
  <patient>
    <reference value="Patient/p-001"/>
    <display value="Jane Patient"/>
  </patient>
  <created value="2025-11-15"/>
  <insurer>
    <reference value="Organization/ins-001"/>
    <display value="Acme Health Insurance"/>
  </insurer>
  <requestor>
    <reference value="Organization/org-001"/>
    <display value="Acme Health Center"/>
  </requestor>
  <request>
    <reference value="Claim/claim-001"/>
    <display value="OP consult claim"/>
  </request>
  <outcome value="complete"/>
  <disposition value="Approved per plan rules. Member copay applied."/>
  <preAuthRef value="PA-556677"/>
  <item>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible"/>
        </coding>
      </category>
      <amount>
        <value value="100"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="Copay"/>
        </coding>
      </category>
      <amount>
        <value value="20"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit amount"/>
        </coding>
      </category>
      <amount>
        <value value="80"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <detail>
      <detailSequence value="1"/>
      <adjudication>
        <category>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/adjudication"/>
            <code value="eligible"/>
            <display value="Eligible"/>
          </coding>
        </category>
        <amount>
          <value value="100"/>
          <currency value="USD"/>
        </amount>
      </adjudication>
      <subDetail>
        <subDetailSequence value="1"/>
        <adjudication>
          <category>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/adjudication"/>
              <code value="benefit"/>
              <display value="Benefit amount"/>
            </coding>
          </category>
          <amount>
            <value value="80"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </subDetail>
    </detail>
  </item>
  <addItem>
    <productOrService>
      <coding>
        <system value="http://example.org/codes/payer-adjustment"/>
        <code value="ADJ001"/>
        <display value="Administrative adjustment"/>
      </coding>
    </productOrService>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </addItem>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
        <display value="Submitted Amount"/>
      </coding>
    </category>
    <amount>
      <value value="100"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="copay"/>
        <display value="Copay"/>
      </coding>
    </category>
    <amount>
      <value value="20"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="benefit"/>
        <display value="Benefit Amount"/>
      </coding>
    </category>
    <amount>
      <value value="80"/>
      <currency value="USD"/>
    </amount>
  </total>
  <payment>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
        <code value="payment"/>
        <display value="Payment"/>
      </coding>
    </type>
    <date value="2025-11-16"/>
    <amount>
      <value value="80"/>
      <currency value="USD"/>
    </amount>
    <identifier>
      <system value="http://payer.example.org/erds"/>
      <value value="EPI-778899"/>
    </identifier>
  </payment>
  <processNote>
    <number value="1"/>
    <type value="display"/>
    <text value="Approved per plan. Member copay applied."/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="en"/>
        <display value="English"/>
      </coding>
    </language>
  </processNote>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/cov-001"/>
      <display value="Primary PPO coverage"/>
    </coverage>
  </insurance>
</ClaimResponse>