Template
Use the following template to fill in claims: (template) Claim.Submission CCAD.xlsx
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The table below describes each column in the expected Excel file. Both xls or xlsx formats are supported.
| Worksheet | Column | Mandatory | Description | Possible Values |
|---|---|---|---|---|
| Generated Claims | Sender ID | Yes | The license number of a healthcare entity that is the sender of the transaction. | |
| Receiver ID | Yes | The license number of a healthcare entity that is the receiver of the transaction. | ||
| Prescription No | Yes | 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. | ||
| Fill Counter | Yes | |||
| Payer ID | Yes | If the patient is claiming insurance cover, this is the Insurer's license number. Other values:
| https://www.doh.haadgov.ae/shafafiya > Dictionary > en/Shafafiya/dictionary > Licenses > Insurers | |
| Provider ID | Yes | 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. | https://www.doh.haadgov.ae/shafafiya > Dictionary > en/Shafafiya/dictionary > Licenses > Facilities | |
| Patient File No | Yes | The unique number a healthcare provider assigns to the patient. This is often known as the medical record number. | ||
| Member ID | Yes | The patient’s insurance member number if the patient is claiming insurance. Otherwise, it equals to Provider ID#Patient File No. | ||
| Emirates ID | Yes | The unique number the government assigns to a citizen. | NNN-NNNN-NNNNNNN-N When Emirates ID is not available:
| |
| Start Date and Time | Yes | 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. | mm/dd/yyyy hh:mm | |
| Encounter Type | Yes | 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 | |
| Encounter Start Type | Yes | The type which defines how the encounter started. | 1 = Elective | |
| Patient Name | No | First name and last name of the patient. | ||
| No | Personal email address of the patient. | |||
| Mobile | No | Mobile number of the patient. | ||
| Principal Diagnosis Code | Yes | A diagnosis code that identifies the principal diagnosis for the condition established after examination, the nature of a disease or illness. | ||
| Secondary Diagnosis Code 1 ... Secondary Diagnosis Code N | No | A diagnosis codes that identify all conditions co-existing at the time of admission, or developing subsequently which affect the treatment received and/or the length of stay. | ||
| Activity Type | Yes | The type of an activity/procedure. | 3 = CPT 4 = HCPCS 5 = Trade Drug 6 = Dental 8 = Service Code 9 = DRG | |
| Activity Code | Yes | An activity code, specified by its type for the activity performed. | ||
| Quantity | Yes | The number of units for an activity. | NNN.DDDD | |
| Gross | No | Total charges for an activity. | ||
| Patient Share | No | Any fee that payer is expecting the provider to collect from the patient. | ||
| Net | Yes | The net charges billed by the provider to the payer for an activity. | ||
| Ordering Clinician | Yes | The license number of the clinician who ordered the service or referred the patient for the service. | https://www.haaddoh.gov.ae/en/Shafafiya/shafafiyadictionary > Dictionary > Licenses > Clinicians | |
| Clinician | No | The license number of the clinician responsible for the activity. In general, this is the person providing the treatment or care for the patient. | https://www.doh.haadgov.ae/shafafiya > Dictionary > en/Shafafiya/dictionary > Licenses > Clinicians | |
| Prior Authorization No | No | The corresponding prior authorization number. | ||
| Lawson No. | No |
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