Claim.Submission for CCAD

Template

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

Data description

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.
	Payer ID	Yes	If the patient is claiming insurance cover, this is the Insurer's license number. 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 paying directly for services provided - 'SelfPay'; If the patient neither claims insurance nor pays directly for services provided - 'ProFormaPayer'; 'MedicalTourismSelfPay'; 'MedicalTourismOther'.	https://www.doh.gov.ae/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.gov.ae/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: 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.
	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 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
	Encounter Start Type	Yes	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
	Insurance Plan	No	Benefit package name.	https://www.doh.gov.ae/en/Shafafiya/dictionary > Codes > Benefit Packages
	Patient Name	No	First name and last name of the patient.
	Email	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.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 No	No	The corresponding prior authorization number.
	Rx Date	Yes	Date of prescription.	mm/dd/yyyy
	Rx Number	Yes	Prescription number.
	Refill Number	Yes	Prescription fill counter.	whole number >= 0
	Total Refills	Yes	Total prescribed refills.	whole number in the range 0 - 3
	Lawson No.	No	Lawson number.
	Dose	Yes	Number of units per the prescribed dose.
	Dose Type	Yes	The type of the drug dose.	unit ml drop app puff IU spray
	Frequency	Yes	The number of dosing interval per time unit of the dispensed medication.	whole number >= 0
	Frequency Type	Yes	Unit of time defining the frequency of the drug dose.	18H, 36H D, 2D, 3D, 4D, 5D, 6D W, 2W, 3W, 4W, 5W, 6W, 7W, 8W M, 2M, 3M, 4M, 5M, 6M, 7M, 8M, 9M, 10M, 11M Y PRN
	Duration	Yes	Duration of the treatment of the dispensed medication in days.	whole number >= 0
	Rx Instructions	No	The prescription / order instructions on how the dispensed medication should be taken by the patient.	free text
	Disease Score	No	The disease score.	whole number in the range 0 - 100
	Disease Score Type	No	The disease score type.	IGA EASI

Self-pay patients

If a patient pays directly for the services provided (pays out of pocket), then the following values must be set:

Receiver ID = HAAD
Payer ID = SelfPay (note that the value is case sensitive)
Member ID = Provider ID#Patient File No (e.g. PF2761#12345)

Template: (template) Claim.Submission CCAD SelfPay.xlsx