Remittance.Advice DoH

Template

Use the following template to fill in remittances: (template) Remittance.Advice.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.haad.ae/shafafiya > Dictionary > Licenses > Insurers
	Receiver ID	Yes	The license number of a healthcare entity that is the receiver of the transaction.	https://www.haad.ae/shafafiya > Dictionary > Licenses > Facilities
	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	Yes	A unique number assigned by an insurer to identify the claim. It helps the provider and payer to locate the claim.
	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.haad.ae/shafafiya > Dictionary > Licenses > Facilities
	Payment Reference	Yes	A unique identifier for the payment transaction that depends on the way of payment: the check number for payments by a check; bank transfer number for payment by a bank transfer; payment voucher number for cash payments.
	Date Settlement	No	The date the payer settles the claim. This is the date that payment is made. If the payment is made in several steps, the latest date is used. If the value of the claim agreed by the payer is 0, the settlement does not entail payment.	dd/mm/yyyy
	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.haad.ae/shafafiya > Dictionary > Licenses > Facilities
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.
	List	No	The list price before any adjustments of discounts.
	Ordering Clinician	Yes	The license number of the clinician who ordered the service or referred the patient for the service.	https://www.haad.ae/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.haad.ae/shafafiya > Dictionary > Licenses > Clinicians
	Prior Authorization ID	No	The corresponding prior authorization number.
	Gross	No	The total amount of the charges included in the activity. It is any patient financial responsibility for the activity, such as co-pays and deductibles, as well as charges made to other insurers for the encounter(s) covered by the activity.
	Patient Share	No	Any fee that payer is expecting the provider to collect from the patient.
	Payment Amount	Yes	The amount paid by the payer towards the provider’s claim.
	Denial Code	No	Payer's reason for the activity denial, as represented by a code.	https://www.haad.ae/shafafiya > Dictionary > Codes > Other Codes

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Remittance.Advice DoH

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