Template

Use the following template to fill in claims: (template) Claim.Submission.xlsx

Data Description

The table below describes each column in the expected Excel file. Some columns are always required (Mandatory = Yes), some are optional, and some are conditional (depend on data entry).

Worksheet	Column	Mandatory	Description	Possible Values
Claims	Sender ID	Yes	The license number (eClaimLink ID) of a healthcare entity that is the sender of the transaction.	https://www.eclaimlink.ae > DHD > Codes and Lists > Providers
	Receiver ID	Yes	The license number (eClaimLink ID) of a healthcare entity that is the receiver of the transaction.	https://www.eclaimlink.ae > DHD > Codes and Lists > Payers
	Claim ID	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.
	ID Payer	No	A unique number assigned by an insurer to identify the claim. It helps the provider and payer to locate the claim.
	Member ID	No	The patient’s insurance member number, if the patient is claiming insurance. Otherwise, the field is empty.
	Payer ID	No	If the patient is claiming insurance cover, this is the Insurer's license number. - For self-paid schemes, this is the eClaimLink Self Paid scheme ID assigned by the DHA. - Otherwise, the field is empty.	https://www.eclaimlink.ae > DHD > Codes and Lists > Payers
	Provider ID	No	The license number (eClaimLink ID) of the provider claiming from the payer. - This can be a facility or a clinician. - Provider ID is sometimes also known as the billing provider. - In general, the facility that hosted the encounter is also the one that claims from the payer. In these cases, Provider ID = Facility ID.	https://www.eclaimlink.ae > DHD > Codes and Lists > Providers
	Weight	No	The patient's weight in kilograms. - For DRG purposes, patient weight is mandatory for newborn and neonate encounters. - IR DRG definition of the Neonatal period: Age on admission is 7 days or less. - The newborn/neonatal period is exactly 7 days commencing on the date of birth (day 0) and ending on the completion of day 7. - The birth weight is limited to be between 150 grams and 9000 grams.
	Emirates ID Number	Yes	The unique number the government assigns to a citizen.	NNN-NNNN-NNNNNNN-N When Emirates ID is not available: 000-0000-0000000-0 - National without card; 111-1111-1111111-1 - Expatriate resident without a card; 222-2222-2222222-2 - Non-national, non-expat resident without a card; 999-9999-9999999-9 - Unknown status, without a card.
	Facility ID	No	The license number (eClaimLink ID)of the facility responsible for the encounter.	https://www.eclaimlink.ae > DHD > Codes and Lists > Providers
	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 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	Yes	The unique number a healthcare provider assigns to a patient. This is often known as the medical record number.
	Encounter Start	Yes	The date and time at which the patient comes under the care of a responsible clinician. For Elective patients, this will typically be the date and time of the visit registration/admission on arrival of the patient at the healthcare facility. For Emergency patients, this will typically be the date and time of the registration and admission on arrival of the patient at the healthcare facility. For Transfer patients between facilities (i.e. inter-hospital transfers), this will typically be the date and time of the visit registration and admission on arrival of the patient at the receiving healthcare facility. For Livebirth this will typically be the date and time of the registration and admission of the newborn at the healthcare facility. The Encounter start will also be the date and time of birth. For Stillbirth this will typically be the date and time of the registration of the stillborn at the healthcare facility. The Encounter start will also be the date and time of stillbirth. For Death on arrival, this will typically be the date and time of the visit registration on arrival of the patient at the healthcare facility for pronouncement.	dd/mm/yyyy hh:mm
	Encounter End	No	The time the patient ceases to be under the direct care of a responsible clinician. For inpatients and day patients this is the discharge date and time. For emergency patients, this is the time that the patient was released from the ER. Not required for outpatients.	dd/mm/yyyy hh:mm
	Encounter Start Type	No	The type which defines how the encounter started.	1 = Elective 2 = Emergency 3 = Transfer 4 = Live birth 5 = Still birth 6 = Dead on arrival 7 = Continuing encounter
	Encounter End Type	No	The type which defines 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	No	The license number (eClaimLink ID) of the healthcare facility from where a hospital transfer originated (Encounter Start Type = 3 Transfer). - If the patient has insurance coverage, it is eClaimLink insurance ID. - If the patient is neither insured by a DHA insurance nor paying - SelfPay.
	Transfer Destination	No	The license number (eClaimLink ID) of the healthcare facility to which a hospital transfer is made at the end of an Encounter (Encounter End Type = 4 Transfer). - If the patient has insurance coverage, it is eClaimLink insurance ID.
	Patient Instructions	No	Patient instructions for the claim.
	Comments	No	Comments to the claim.
	Attachment	No	Required attachment to prove a claim.	attached file name with extension (if located in the same folder as the Excel file); the full file name with the path (if located in another folder) Extension: .pdf, .jpg, .jpeg
	Resubmission Type	No	The type of resubmission of a claim.	correction internal complaint
	Resubmission Comment	No	The comment left by the provider during the resubmission, e.g. explanation of the reason for such action.
	Resubmission Attachment	No	The required attachment which needs to be added during resubmission to prove a claim.	Extension: pdf
	Package Name	No	The name of the insurance package.
Diagnoses	Claim ID	Yes	Reference to Claim ID on Claims worksheet
	Diagnosis Type	Yes	The type of diagnosis being recorded. Principal - Identifies the principal diagnosis for the condition established after examination, the nature of a disease or illness. Secondary - All conditions that co-exist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. Admitting - The diagnosis that the physician identifies at the time of admission.	Principal Secondary Admitting
	Diagnosis Code	Yes	The value for the diagnosis code as per the coding manual.	ICD10-CM
	Dx Info Type	No	The type of additional information for the diagnosis. Present On Admission (POA) indicator it refers to the associated diagnosis code and is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. The POA Indicator is applied to the principal diagnosis as well as all secondary diagnoses and the external cause of injury codes that are reported.	POA
	Dx Info Code	No	The code value related to the DxInfoType. Y = Yes. Present at the time of inpatient admission. N = No. Not present at the time of inpatient admission. U = Unknown. Documentation is insufficient to determine if the condition is present on admission. W = Clinically undetermined. The provider is unable to clinically determine whether the condition was present on admission or not. 1 = Unreported / Not used. Exempt from POA reporting. OP = Outpatient claim. This is an outpatient claim which does not require DRGsin Dubai (for the time being).	Y = Yes N = No U = Unknown W = Clinically undetermined 1 = Unreported / Not used OP = Outpatient claim
Activities	Claim ID	Yes	Reference to Claim ID on Claims worksheet
	Activity ID	Yes	Unique identifier of activity within a claim.
	Activity Start	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.	dd/mm/yyyy hh:mm
	Activity Type	Yes	The type of activity/procedure.	3 = CPT 4 = HCPCS 5 = Trade Drug 6 = Dental 8 = Service Code 9 = DRG 10 = Scientific Code
	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
	Net	Yes	The net charges billed by the provider to the payer for an activity.
	Patient Share	No	The amount a patient owes the provider according to the terms of their insurance plan/product. - If the patient has no insurance coverage for the visit, they are considered self-pay and liable for the entire amount, per their signed consent for treatment.
	Clinician	Yes	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.eclaimlink.ae > DHD > Codes and Lists > Clinicians
	Prior Authorization ID	No	The corresponding prior authorization number.
	Patient Instructions	No	Patient instructions for the activity.
	Comments	No	Comments to the activity.
	Attachment	No	Required attachment to prove the activity.	attached file name with extension (if located in the same folder as the Excel file); full file name with the path (if located in another folder) Extension: .pdf, .jpg, .jpeg
Observations	Claim ID	No	Reference to Claim ID on Claims worksheet
	Activity ID	No	Reference to Activity ID on Activities worksheet
	Observation Type	No	The type of observation	LOINC Text File Universal Dental Financial Grouping ERX Result ROM (Risk of Mortality) ExcludeFromDRG
	Observation Code	No	The code describing the observation value.
	Observation Value	No	The observed value of the activity. Restriction: Must be expressed in SI Units.
	Observation Value Type	No	Unit of measure for the observation value.

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