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 of a healthcare entity that is the sender of the transaction.	https://www.doh.gov.ae/en/Shafafiya/dictionary > Licenses > Facilities
	Receiver ID	Yes	The license number of a healthcare entity that is the receiver of the transaction.	https://www.doh.gov.ae/en/Shafafiya/dictionary > Licenses > Insurers
	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	Yes	The patient’s insurance member number, if the patient is claiming insurance. Otherwise, it equals to Facility ID#Patient ID.
	Payer ID	No	If the patient is claiming insurance cover, this is the Insurer's license number.	https://www.doh.gov.ae/en/Shafafiya/dictionary > Licenses > Insurers Other values: If the patient is claiming insurance from an Insurer not included in the list of valid licenses - '@' followed by the name of the Insurer; If the patient is a resident of the Emirate of Abu Dhabi and is paying directly for services provided - SelfPay; If the patient is a resident of the Emirate of Abu Dhabi and neither claims insurance nor pays directly for services provided - ProFormaPayer; If the patient is not a resident of the Emirate of Abu Dhabi and is paying directly for services provided -MedicalTourismSelfPay; If the patient is not a resident of the Emirate of Abu Dhabi and neither claims insurance nor pays directly for services provided - MedicalTourismOther.
	Provider ID	No	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.gov.ae/en/Shafafiya/dictionary > Licenses > Facilities
	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 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.	https://www.doh.gov.ae/en/Shafafiya/dictionary > Licenses > Facilities
	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 10 = Telemedicine 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.
	Eligibility ID Payer	No	The AuthorizationIDPayer provided by the Insurer/TPA in the latest Eligibility transaction. Used to demonstrate that the payer has confirmed the patient’s eligibility.
	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 would be the discharge date and time. For emergency patients this would be the time that the patient was released from the ER.	dd/mm/yyyy hh:mm
	Encounter Start Type	No	The type which defines how the encounter started.	1 = Elective 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	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 8 = Telemedicine resulting in Emergency Management 9 = Telemedicine resulting in Prescription 10 = Telemedicine resulting in Referral 11 = Telemedicine resulting in Follow Up 12 = Telemedicine resulting in Self Care
	Transfer Source	No	The license number of a healthcare facility from where a hospital transfer originated (Encounter Start Type = 3 Transfer). If the facility is not in the list of licensed providers, it equals to '@' followed by the name of the facility.
	Transfer Destination	No	The license number of a healthcare facility to which a hospital transfer is made at the end of an encounter (Encounter End Type = 4 Transfer). If the facility is not in the list of licensed providers, it equals to '@' followed by the name of the facility.
	Patient Instructions	No	Patient instructions for a claim.
	Comments	No	Comments to a 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 legacy
	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 plan.	https://www.doh.gov.ae/en/Shafafiya/dictionary > Codes > Benefit Packages
	Patient Name	No	First name and last name of the patient.
	Email	No	The personal email address of the patient.
	Mobile	No	The mobile number of the patient.
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. Reason For Visit	Principal Secondary Admitting ReasonForVisit
	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.	POA Year of Onset Birth Weight ICD10-GM ICD10-CM KCD
	Dx Info Code	No	The code value related to the DxInfoType.	POA: Y = Yes N = No U = Unknown W = Clinically Undetermined 1 = Unreported/Not used Year of Onset: YYYY (the year of first time the Patient had the diagnosis established) Birth Weight: GGGG (the patient's birth weight in grams)
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
	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	Any fee that payer is expecting the provider to collect from the patient.
	Ordering Clinician	Yes	The license number of the clinician who ordered the service or referred the patient for the service.	https://www.doh.gov.ae/en/Shafafiya/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.gov.ae/en/Shafafiya/dictionary > Licenses > Clinicians
	Prior Authorization ID	No	The corresponding prior authorization number.
	VAT	No	The Value Added Tax amount appropriated for the activity.	number, two decimals
	VAT Percent	No	The Value Added Tax rate.	[0...100], one decimal
	Patient Instructions	No	Patient instructions for an activity.	Free text
	Comments	No	Comments to an activity.	Free text
	Attachment	No	Required attachment to prove an 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
	Tooth Numbers	No	Tooth numbers required for an activity with Activity Type = 6 (Dental), comma separated. An alternative way to fill in Universal Dental observations: all teeth in one line.
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.	CPT HL7v3 Native LOINC SNOMED CT Text File Flags Universal Dental Episode
	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.

Data Management

Cash claims

If a patient pays for provided services himself (so-called self-pay patients to cash patients), then the following values must be set in your Claim.Submission transactions:

Receiver ID = HAAD
Payer ID = SelfPay or ProFormaPayer or MedicalTourismSelfPay or MedicalTourismOther (depending on the residence of the patient, see below)
Member ID = Facility ID#Patient ID (e.g. MF123#12345)

Note that all values are case sensitive.

Template: (template) Claim.Submission SelfPay.xlsx

Patient share for drugs

There are two options for how to set Patient Share for a Trade Drug (Activity.Type = 5 (Trade Drug)) on Activity level.

Option 1. Use Patient Share column on Activities tab of Excel file. We suggest using this option as it is a very simple one.

Option 2. Add the corresponding observation on Observations tab of Excel file with the details:

Observation Type = Text;
Observation Code = Drug patient share;
Observation Value = <amount in AED>;
Observation Value Type = AED.

In both cases, Patient Share is generated as Activity.Observation block in the XML. Only one Patient Share Observation is allowed per Trade Drug.

For activities with Activity.Type <> 5, Patient Share is set on Activities tab only.

Claim.PatientShare is calculated as the sum of Patient Share for all activities in a claim.

Electronic Medical Invoice

According to DoH circular US/12/19 issued on March 14, 2019, providers must send a copy of e-claims to the patients by email or SMS. The effective date for this requirement is June 1, 2019. Use the following columns on Claims worksheet to add contact data of the patient:

Patient Name
Email
Mobile

When Claim.Submission transaction is generated, then uploaded with the means of Greenrain Messenger, an email (medical invoice) is sent to the patient by email with the claim details attached as a pdf file. Electronic medical invoice is sent if the following conditions are met:

at least column Email from the list above has a value;
setting VAT TRN has a value (Tools > Settings > General tab);
a claim is not a resubmission.

Greenrain Submission Help

Claim.Submission DoH