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Template
Use the following template to fill in remittances: (template) Claim.Submission.xlsx
Data description
The table below describes each column in expected Excel file.
| Worksheet | Column | Description | Possible Values |
|---|---|---|---|
| Claims | Sender ID | The license number of a healthcare entity that is the sender of the transaction. | |
| Receiver ID | The license number of a healthcare entity that is the receiver of the transaction. | ||
| Claim ID | A unique number assigned by a healthcare provider to identify the claim. This is also known as the provider’s claim reference number. If the patient is not insured and pays out of pocket, this is the external invoice reference number. | ||
| ID Payer | A unique number assigned by an insurer to identify the claim. It helps the provider and payer to locate the claim. | ||
| Member ID | The patient’s insurance member number, if the patient is claiming insurance. Otherwise, it equals to EncounterFacilityID#EncounterPatientID. | ||
| Payer ID | If the patient is claiming insurance cover, this is the Insurer's license number. Other values:
| www.haad.ae/dictionary >> Licenses | |
| Provider ID | The facility license number of the healthcare provider claiming from the payer. If the provider has no valid license number, the provider is '@' followed by the name of the provider. | ||
| Emirates ID Number | The unique number the government assigns to a citizen. When an EmiratesIDNumber is not available :
| ||
| Facility ID | The license number of the facility responsible for the encounter. If the reported encounter happened in a not licensed facility, it equals to '@' followed by the name of the facility. | ||
| Encounter Type | The type of encounter (inpatients, daycases, emergencies and outpatients). They vary according to whether the encounter went past midnight, lasted for more than 24 hours, involved a hospital bed and whether they involved an emergency room. | 1 = No Bed + No emergency room 2 = No Bed + Emergency room 3 = Inpatient Bed + No emergency room 4 = Inpatient Bed + Emergency room 5 = Daycase Bed + No emergency room 6 = Daycase Bed + Emergency room 7 = Nationals Screening 8 = New Visa Screening 9 = Renewal Visa Screening 12 = Home 13 = Assisted Living Facility 15 = Mobile Unit 41 = Ambulance - Land 42 = Ambulance - Air or Water | |
| Patient ID | The unique number a healthcare provider assigns to a patient. This is often known as the medical record number. | ||
| Eligibility ID Payer | The AuthorizationIDPayer provided by the Insurer/TPA in the latest Eligibility transaction (PriorAuthorization with AuthorizationType=Eligibility). Used to demonstrate that the payer has confirmed patient’s eligibility. | ||
| Encounter Start | The date and time at which the patient comes under the care of a responsible clinician.
| ||
| Encounter End | The time the patient ceases to be under the direct care of a responsible clinician.
| ||
| Encounter Start Type | 1 = Elective, i.e., an Encounter is scheduled in advance 2 = Emergency 3 = Transfer admission from acute care 4 = Live birth 5 = Still birth 6 = Dead On Arrival 7 = Continuing Encounter 8 = Transfer admission from non-acute care | ||
| Encounter End Type | How the patient was discharged. 1 = Discharged with approval 2 = Discharged against advice 3 = Discharged absent without leave 4 = Discharge transfer to acute care 5 = Deceased 6 = Not discharged 7 = Discharge transfer to non-acute care. | ||
| Transfer Source | EncounterTransferSource is the healthcare facility from where a hospital transfer originated (EncounterStartType = 3 Transfer). The originating healthcare facility is described by facility license number. Lists of valid license numbers are available on www.shafafiya.org/dictionary >> Licenses. If the facility is not in the list of licensed providers, enter “@” followed by the name of the facility. | ||
| Transfer Destination | EncounterTransferDestination is the healthcare facility to which a hospital transfer is made at the end of an Encounter (EncounterEndType = 4 Transfer). This is facility license number. Lists of valid license numbers are available on www.shafafiya.org/dictionary >> Licenses. If the facility is not in the list of licensed providers, enter “@” followed by the name of the facility. | ||
| Resubmission Type | The type of resubmission of a claim or prior request. Validation rule: value ‘legacy’ is not allowed for PriorRequest | ||
| Resubmission Comment | |||
| Package Name | |||
| Diagnoses | Claim ID | Reference to Claim ID on Claims worksheet | |
| Diagnosis Type | The type of diagnosis being recorded. Principal: Identifies the principal diagnosis code (full ICD-9-CM) for the condition established after examination. It will identify the nature of a disease or illness. • Inpatients | Condition established, after study, to be chiefly responsible for occasioning the admission of the patient to the hospital for care. • Ambulatory patients | The condition or problem that explains the clinician’s assessment of the presenting symptoms/problems and corresponds to the tests or services provided. This assessment may be a suspected diagnosis or a rule-out diagnosis and is based on the patient’s presenting history and physical and the physician’s review of symptoms. This may also be a symptom where the underlying cause has yet to be determined Secondary: • Inpatients | All conditions that co-exist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. Diagnoses that refer to an earlier episode that have no bearing on the current hospital stay are to be excluded. Conditions should be coded that affect patient care in terms of requiring: Clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care and/or monitoring. • Ambulatory patients | All co-existing conditions, including chronic conditions that exist at the time of the Encounter or visit and require or affect patient management. • External causes of injury, poisoning or adverse affect are coded as supplementary codes to the diagnosis codes of the actual condition such as “Motor Vehicle Accident” that caused a fracture of the tibia. Note | For quality purposes, it is important to be able to track Hospital-acquired infections. The corresponding E-Code is 849.7 Admitting: The diagnosis that the physician identifies at the time of admission. Note | This diagnosis might differ from EncounterDiagnosisPrincipal. | ||
| Diagnosis Code | The value for the diagnosis code as per coding manual. | ||
| Dx Info Type | The type of additional information for the diagnosis. POA : Present On Admission (POA) indicator | ||
| Dx Info Code | The code value related to the DxInfoType. | ||
| Activities | Claim ID | Reference to Claim ID on Claims worksheet | |
| Activity ID | Unique identifier of an activity within a claim. | ||
| Activity Start | The date and time at which an activity started. For a DRG code, it is the date and time of discharge. If the date, but not the time is recorded, the time is assumed to be 00:00. | ||
| Activity Type | The type of an activity/procedure. | 3 = CPT; 4 = HCPCS; 5 = Trade Drug; 6 = Dental; 8 = Service Code; 9 = IR-DRG; 10 = Generic Drug. | |
| Activity Code | An activity code, specified by its type for the activity performed. | ||
| Quantity | The number of units for an activity. | NNN.DDDD | |
| Net | The net charges billed by the provider to the payer for an activity. | ||
| Patient Share | Any fee that payer is expecting the provider to collect from the patient. | ||
| Ordering Clinician | The license number of the clinician who ordered the service or referred the patient for the service. | ||
| Clinician | The license number of the clinician responsible for the activity. In general, this is the person providing the treatment or care for the patient. | ||
| Prior Authorization ID | The corresponding prior authorization number. | ||
| Observations | Claim ID | Reference to Claim ID on Claims worksheet | |
| Activity ID | Reference to Activity ID on Activities worksheet | ||
| Observation Type | CPT"/> "LOINC"/> "Text"/> "File"/> "Universal Dental | ||
| Observation Code | The code describing the Observation value. | ||
| Observation Value | The observed value of the Activity. Restriction: Must be expressed in SI Units. | ||
| Observation Value Type | Unit of measure for the ObservationValue. |