Claim.Submission Riayati

Template

Use the following template to fill in claims: (template) Claim.Submission - Riayati.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. Should be synchronized with LMU License ID.
	Receiver ID	Yes	The license number of a healthcare entity that is the receiver of the transaction. Should be synchronized with LMU HIC or TPA ID.
	Payer ID	Yes	HIC or Self Paid ID allowed licenses registered in the Riayati LMU. HIC or Self Paid License if Receiver ID is TPA. If Receiver ID is HIC, Payer ID must be equal to Receiver ID. If Payer ID is SP, Receiver ID must be TPA.
	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 (SP), 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.
	Type	Yes	Claim type. Can be: Submission - normal claiming (original claim); Resubmission - resubmission entry (correction or internal complaint); Prescription - dispensed prescription.	Submission Resubmission Prescription
	Member ID	Yes	The patient’s insurance member number if the patient is claiming insurance.
	Dispensed ID	No	Dispensed number. Required if Type = Prescription.
	Provider ID	Yes	The facility license number of the healthcare provider claiming from the payer.
	Weight	No	The patient's weight.	Float with max 2 digits in the decimal part (for example, 50.0, 76.70)
	National ID Number	Yes	The unique number the government assigns to a citizen. Also knows as Emirates ID or EID.	NNN-NNNN-NNNNNNN-N When National ID Number is not available: 000-0000-0000000-0 = National without a 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.
	Reference Number	No	The unique number assigned to the request dispense. This is the Reference Number for eRx. Required if Type = Prescription.
	Date Of Birth	Yes	The date of birth of the patient.	dd/mm/yyyy
	Gender	Yes	The patient's sex.	Male Female
	Facility ID	Yes	The license number of the facility responsible for the encounter.
	Encounter Type	Yes	The type of encounter (inpatients, day cases, 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 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.
	Transfer Source	No	The license number of a healthcare facility from where a hospital transfer originated (Encounter Start Type = 3).
	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).
	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
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.	Principal Secondary
	Diagnosis Code	Yes	The value for the diagnosis code as per the ICD10-CM coding manual.	ICD10-CM
	Dx Info Type	No	The type of additional information for the diagnosis: POA or Present on Admission (present at the time the order for inpatient admission occurs).	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 condition is present on admission; W = Clinically Undetermined, provider is unable to clinically determine whether condition was present on admission or not; 1 = Unreported/Not used, exempt from POA reporting; OP = Outpatient, this is an outpatient claim which does not require DRGs.	Y = Yes N = No U = Unknown W = Clinically Undetermined 1 = Unreported/Not used OP = Outpatient
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 9 = DRG
	Activity Code	Yes	An activity code, specified by its type for the activity performed. Should be Sync with LMU.
	Location	No	The location of the activity, used to identify the type of the visit when this service has been dispensed. It is designed to help payer’s differential activities taken / dispensed in the ER versus IP versus discharge prescription versus any other location since each group of activities serviced at different locations are subject to a different set of benefits at the payer.	1 = Inpatient 2 = Outpatient 3 = Emergency 4 = Home 5 = Ambulance 6 = Health Campaign 7 = After Discharge
	Quantity	Yes	The number of units for an activity.	Float with max 2 digits in the decimal part (for example, 1.0, 5.25)
	Net	Yes	The net charges billed by the provider to the payer for an activity.	Float with max 3 digits in the decimal part (for example, 120, 260.125)
	Patient Share	No	Any fee that payer is expecting the provider to collect from the patient.	Float with max 3 digits in the decimal part (for example, 12, 10.875)
	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. Exceptions: the clinician is the ordering physician for labs, x-rays, prescriptions, other tests; the clinician is the attending consultant physician at the time of discharge of the patient from the hospital if the activity is an inpatient service code.
	Duration	No	Identifies the duration in days for the prescribed activity. Required for an activity with Activity Type = 5.	Float with max 2 digits in the decimal part (for example, 10.50)
	Prior Authorization ID	No	The corresponding prior authorization number.
	Dispensed Activity ID	No	Represents the activity ID from the transaction the provider wants to dispense. Required if Type = Prescription.
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.	ERX ExcludeFromDRG File Financial Grouping LOINC OfflineAuthorization Refill Text UniversalDental
	Observation Code	No	The code describing the observation value.	LOINC, Description, Modifier, Duration, InvoiceNumber, InvoiceDate, File , UniversalNumberingSystemDental, ActivityGross, PSDeductible, PSCoPayment, PSOutOfPocket, DRGInlierPayment, DRGOutlierPayment, DRGTransferPayment, DRGTotalPayment, ActivityCost, ActivityPatientShare, BundleID, PackageID, ExcludeFromDRG, EncounterID, eRxReferenceNo, Refill, Prescription, OfflineAuthorization
	Observation Value	No	The observed value of the activity.
	Observation Value Type	No	Unit of measure for the observation value.