Health Authority Abu Dhabi

60 Pages·2007·0.42 MB·English

Health Authority Abu Dhabi
Reliable Excellence in Healthcare
Encounter/ September 20
2007
Claims Guidance
Health Authority Abu Dhabi
Reliable Exceellence in Healthcare

Publisher
Health Authorityy Abu Dhabi

[phone]
[phone]
P.O.Box 5674 Abu Dhabi, United Arab Emirates
www.haad.ae [email protected]

© 20007
Health Authority Abu Dhabi
Reliable Excellence in Healthcare
Contents
1 Introduction ................................................................................................................................................................................................ 1
1 Key definitions and principles ................................................................................................................................................................... 2
Claim ........................................................................................................................................................................................................................................... 2
Encounter .................................................................................................................................................................................................................................... 2
How claims and Encounters relate to records ............................................................................................................................................................................. 2
Record ......................................................................................................................................................................................................................................... 4
Activity ........................................................................................................................................................................................................................................ 4
2 What to submit to HAAD .......................................................................................................................................................................... 5
Record fields ............................................................................................................................................................................................................................... 5
Required fields ............................................................................................................................................................................................................................ 7
Which Encounters/Claims to include .......................................................................................................................................................................................... 9
How to Claim non‐paying non‐insured patients .......................................................................................................................................................................... 9
File format ................................................................................................................................................................................................................................. 10
3 When to submit data .............................................................................................................................................................................. 10
4 How to submit data ................................................................................................................................................................................ 10
Requirements ............................................................................................................................................................................................................................ 10
Login.......................................................................................................................................................................................................................................... 10
Support for submissions ............................................................................................................................................................................................................ 12
5 Communication standards ...................................................................................................................................................................... 13
6 Field Definitions ...................................................................................................................................................................................... 14
PatientFirstName ...................................................................................................................................................................................................................... 14
PatientContactNumber ............................................................................................................................................................................................................. 15
PatientBirthDate ....................................................................................................................................................................................................................... 16
PatientGender ........................................................................................................................................................................................................................... 17
PatientNationality ..................................................................................................................................................................................................................... 18
ClaimID ...................................................................................................................................................................................................................................... 19
ClaimIDPayer ............................................................................................................................................................................................................................. 20
ClaimIDInvoice .......................................................................................................................................................................................................................... 21
ClaimPatientID .......................................................................................................................................................................................................................... 22
ClaimPayerID ............................................................................................................................................................................................................................. 23
ClaimProviderID ........................................................................................................................................................................................................................ 24
ClaimGross ................................................................................................................................................................................................................................ 25
ClaimPatientShare ..................................................................................................................................................................................................................... 26
ClaimNet ................................................................................................................................................................................................................................... 27
ClaimPaymentAmount .............................................................................................................................................................................................................. 28
ClaimDateSubmitted ................................................................................................................................................................................................................. 29
ClaimDateReceived ................................................................................................................................................................................................................... 30
ClaimDateSettlement ................................................................................................................................................................................................................ 31
ClaimDateSettlementReceived.................................................................................................................................................................................................. 32
ClaimDateLastTransaction ......................................................................................................................................................................................................... 33
ClaimStatus ............................................................................................................................................................................................................................... 34
EncounterID .............................................................................................................................................................................................................................. 36
EncounterPatientID ................................................................................................................................................................................................................... 37
EncounterFacilityID ................................................................................................................................................................................................................... 38
EncounterStart .......................................................................................................................................................................................................................... 39
EncounterStartType .................................................................................................................................................................................................................. 40
EncounterType .......................................................................................................................................................................................................................... 41
EncounterSpecialty ................................................................................................................................................................................................................... 43
EncounterLocation .................................................................................................................................................................................................................... 44
EncounterEnd. ........................................................................................................................................................................................................................... 45
EncounterEndType .................................................................................................................................................................................................................... 46
EncounterDiagnosisPrincipal ..................................................................................................................................................................................................... 47
EncounterDiagnosisSecondary .................................................................................................................................................................................................. 48
EncounterDiagnosisAdmitting ................................................................................................................................................................................................... 49
EncounterTransferSource ......................................................................................................................................................................................................... 50
EncounterTransferDestination .................................................................................................................................................................................................. 51
ActivityStart .............................................................................................................................................................................................................................. 52
ActivityType .............................................................................................................................................................................................................................. 53
ActivityCode .............................................................................................................................................................................................................................. 54
ActivityQuantity ........................................................................................................................................................................................................................ 55
ActivityNet ................................................................................................................................................................................................................................ 56
ActivityClinician ......................................................................................................................................................................................................................... 57
T a b l e o f C o n t e n t s | I
Health Authority Abu Dhabi
Reliable Excellence in Healthcare
1 Introduction
The Vision for the Health System in Abu Dhabi is to provide access to high quality health care services to
all. To enable this, there is a need to monitor and report on activity and quality. This requires data to be
collected from all entities providing heath care and health insurance within the health system of the
Emirate of Abu Dhabi. The data collected should become a byproduct of the routine operations of
providers and insurers, rather than creating an additional or separate burden of information collection.

The aspiration is for the data standards to become self‐sustaining, because they add value for participating
healthcare organizations. Standardising data will create a shared language for healthcare organizations,
thus increasing consistency and transparency, facilitating discussion, and enabling for efficient electronic
communications between healthcare organizations.

This Guidance
• Defines key terms and principles
• Sets out data definitions for all healthcare organizations in Abu Dhabi
• Defines what data needs to be submitted to HAAD by all Hospitals, Primary Healthcare Centers, and
health insurers
• Explains how data needs to be submitted to HAAD

The Guidance will develop as the health system matures. Your feedback on making this document clearer
and easier to understand is welcome.
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1 Key definitions and principles
Claim
A claim is an original request for payment for health services provided to a single patient. A Claim is
typically recorded on a claims form and supported by one or multiple invoices. Claims are generally linked
to patients that are covered by health insurance. For the purposes of this guidance, any invoices made out
to non‐insured patients should also be considered as Claims.
Encounter
An Encounter starts when a patient is first brought under the care of a responsible healthcare professional
and ends when the patient stops being under the care of a responsible healthcare professional at the
healthcare provider.

Example| A patient has an accident at home and is driven by his family to the emergency room of a local
hospital. After triage in the emergency room, the patient is admitted to a ward and has surgery a few hours
later. After five days the patient is discharged home. The time period from being registered in the
emergency room until discharge from the hospital is considered to be one Encounter.

Example | A patient has an outpatient consultation during which she undergoes a lab test and receives a
prescription, which she collects on her way out of the hospital. Four days later she has an x‐ray, and a
further two days later a follow‐up appointment with a doctor. The patient has had three Encounters:
{outpatient consultation + lab test + prescription}, {X‐ray}, {follow‐up appointment}

Example| A patient has an outpatient consultation, during which he receives a lab test, does an x‐ray and
receives a prescription, which he collects on the way out of the hospital. This patient has only one
Encounter. {outpatient consultation + lab test + x‐ray + prescription}

How claims and Encounters relate to records
A Claim often relates exactly to one Encounter. There are cases, however, where there are several claims
related to one Encounter, and conversely when one Claim comprises several Encounters. Thus, to be able
to analyze the data by Encounter or by Claim, every Claim‐Encounter combination should be treated as one
record. This is shown conceptually in the illustration below, and elaborated in the following examples.

Example 1 | A patient is admitted to a hospital for elective surgery and is assigned a hospital bed. The
following items and activities define the hospital stay:
• Room and Board
• Medical and/or surgical procedures
• Clinical laboratory tests
• Physical and occupational therapy services
• Radiological services
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Health Authority Abu Dhabi
Reliable Excellence in Healthcare
• Hearing and vision services
• Transportation services including ambulance
• Medical supplies
• Drugs
All the above activities provided as part of this Encounter would typically be aggregated in one Claim. If this
Encounter was billed to two or more insurers, there would be multiple claims for the same Encounter.

Claim 1 Encounter 1 Claim 1 Encounter 1
Claim 2 Encounter 2 Claim 2 Encounter 2
Encounter 3 Claim 2 Encounter 3
Claim 3 Encounter 4 Claim 3 Encounter 4
Claim 4 Claim 4 Encounter 4

Example 2 | A hospital patient visits a Radiology center, an independently owned laboratory outside the
hospital, for a CAT scan. The laboratory visit would be considered one Encounter and comprises one
Activity (CAT scan). The laboratory would typically bill the insurer for this Encounter as a separate Claim.

Example 3 | A woman delivers a baby at a hospital. The hospital will bill the charges for its activities as one
Claim, although there are two Encounters – one for the mother and one for the baby. All activities related
to the mother Encounter and the baby Encounter will be billed as parts of the same Claim.

Example 4 | In example 1, if the hospital bills insurers A and B for the Encounter, there would be separate
Claims going to Insurer A and Insurer B for only one Encounter. For example, Insurer A provides primary
insurance but does not cover high cost drugs, which are covered by Insurer B.

Example 5| In example 3, the hospital would bill the mother‐related charges separately from the baby‐
related charges, if the mother delivered a sick baby that needs to stay in the hospital after the mother was
discharged. In this example, the mother’s Claim would comprise two Encounters with multiple activities,
but the baby‐related charges would be claimed as a separate Claim.
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Health Authority Abu Dhabi
Reliable Excellence in Healthcare
Record
In many cases there is one Claim per Encounter. In certain cases, however, there are more Claims than
Encounters or more Encounters than Claims. In such cases, the data sets must be split according to the
illustration above:
• If there is one Claim for one Encounter the data should be submitted as one record
• If there are multiple Claims for one Encounter, there should be as many records as there are Claims;
the Encounter information should be repeated for each record
• If a Claim comprises multiple Encounters, there should be as many records as there are Encounters;
the Claims information should be repeated for each record
Note | If a sick newborn is charged as a separate Claim to the mother’s delivery, then the mother’s
Encounter needs to be linked with that Claim, i.e., there needs to be a record with the newborn Claim, and
the mother’s Encounter. Such linking allows an analysis, e.g., of whether the baby was born after the
mother entered the provider as an emergency or as a result of a transfer. This is important information for
quality purposes.

Activity
A Claim may comprise one or many Claim items, often referred to as service items. Analogously, an
Encounter may comprise one or more items, e.g., only a visit to the emergency room (one item), or for
example, a visit to the emergency room followed by an admission, lab test, diagnostics and prescriptions
(five items).
An Activity is any Claim item or Encounter item.
• Generally a Claim item corresponds to an Encounter item, so every Claim item/Activity item is
considered an Activity. This could be the case for example for a first outpatient consultation or a
prescription, two separate activities.
• Some Encounter items however do not correspond with Claim items. For instance, individual
surgical procedures are Encounter items, yet they may be claimed summarily as a DRG or flat fee
(the Claim item). Both the surgical procedures as well as the DRG or flat fee are considered
individual activities.
• Some Claim items don’t have corresponding Encounter items. In the example above, the DRG Claim
item is a Claim item, but not an Encounter item.
Note | Activity information is not a mandatory requirement in the initial phases. To create additional
transparency and allow organizations to plan, this is included here as a data standard.

Each record should contain all non‐chargeable activities relating to the Encounter.

Example | A patient has elective surgery and receives a tailored drug cocktail, which is not covered by his
primary insurance. For this one Encounter the hospital makes two Claims: one to the primary insurance
which is billed as a DRG, and one to the supplementary insurance for the expensive drugs. The two Claims
need to be reported in two separate records. The Encounter information on each record should include
information on the procedures performed, even if they are not charged. On the first Claim the only charge
relates to the DRG; on the second , the only charge relates to the drugs.

Each record should specify those chargeable activities that are related to the Claim.
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Health Authority Abu Dhabi
Reliable Excellence in Healthcare

Example | A patient has an outpatient consultation and receives a prescription. If the provider makes two
separate Claims for this one Encounter. This would result in two records, one covering the consultation and
one covering the prescription. The record claiming the consultation would only have the consultation
Activity, while the record claiming for the prescription would only comprise the prescription Activity.
2 What to submit to HAAD
Record fields
Individual records must contain all fields in the order defined in the illustration on the next page. The blue
fields are primarily administrative. They permit counting of money (Claims) and hospital Activity
(Encounters). The red fields provide insight into “what is wrong with the patient”, i.e., the diagnosis. The
grey fields – the majority – shed light on “what was done with the patient”. They are not mandatory at
present and therefore do not necessarily need to be recorded. They are included here to provide
direction and allow organizations to plan for the future. Individual fields are defined in detail in the chapter
Field Definitions.
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Reliable Excellence in Healthcare
FieldName FieldName FieldName FieldName FieldName
1 PatientFirstName 51 ActivityCode 101 ActivityNet 151 ActivityStart 201 Empty
2 PatientContactNumber 52 ActivityUnits 102 ActivityClinician 152 ActivityType 202 Empty
3 PatientBirthDate 53 ActivityNet 103 ActivityStart 153 ActivityCode 203 Empty
4 PatientGender 54 ActivityClinician 104 ActivityType 154 ActivityUnits 204 Empty
5 PatientNationality 55 ActivityStart 105 ActivityCode 155 ActivityNet 205 Empty
6 ClaimID 56 ActivityType 106 ActivityUnits 156 ActivityClinician 206 Empty
7 ClaimIDPayer 57 ActivityCode 107 ActivityNet 157 ActivityStart 207 Empty
8 ClaimIDInvoice 58 ActivityUnits 108 ActivityClinician 158 ActivityType 208 Empty
9 ClaimPatientID 59 ActivityNet 109 ActivityStart 159 ActivityCode 209 Empty
10 ClaimPayerID 60 ActivityClinician 110 ActivityType 160 ActivityUnits 210 Empty
11 ClaimProviderID 61 ActivityStart 111 ActivityCode 161 ActivityNet 211 Empty
12 ClaimGross 62 ActivityType 112 ActivityUnits 162 ActivityClinician 212 Empty
13 ClaimPatientShare 63 ActivityCode 113 ActivityNet 163 ActivityStart 213 Empty
14 ClaimNet 64 ActivityUnits 114 ActivityClinician 164 ActivityType 214 Empty
15 ClaimPaymentAmount 65 ActivityNet 115 ActivityStart 165 ActivityCode 215 Empty
16 ClaimDateSubmitted 66 ActivityClinician 116 ActivityType 166 ActivityUnits 216 Empty
17 ClaimDateReceived 67 ActivityStart 117 ActivityCode 167 ActivityNet 217 Empty
18 ClaimDateSettlement 68 ActivityType 118 ActivityUnits 168 ActivityClinician 218 Empty
19 ClaimDateSettlementReceived 69 ActivityCode 119 ActivityNet 169 ActivityStart 219 Empty
20 ClaimDateLastTransaction 70 ActivityUnits 120 ActivityClinician 170 ActivityType 220 Empty
21 ClaimStatus 71 ActivityNet 121 ActivityStart 171 ActivityCode 221 Empty
22 EncounterID 72 ActivityClinician 122 ActivityType 172 ActivityUnits 222 Empty
23 EncounterPatientID 73 ActivityStart 123 ActivityCode 173 ActivityNet 223 Empty
24 EncounterFacilityID 74 ActivityType 124 ActivityUnits 174 ActivityClinician 224 Empty
25 EncounterStart 75 ActivityCode 125 ActivityNet 175 ActivityStart 225 Empty
26 EncounterStartType 76 ActivityUnits 126 ActivityClinician 176 ActivityType 226 Empty
27 EncounterType 77 ActivityNet 127 ActivityStart 177 ActivityCode 227 Empty
28 EncounterLocation 78 ActivityClinician 128 ActivityType 178 ActivityUnits 228 Empty
29 EncounterEnd 79 ActivityStart 129 ActivityCode 179 ActivityNet 229 Empty
30 EncounterEndType 80 ActivityType 130 ActivityUnits 180 ActivityClinician 230 Empty
31 EncounterDiagnosisPrincipal 81 ActivityCode 131 ActivityNet 181 ActivityStart 231 Empty
32 EncounterDiagnosisSecondary 82 ActivityUnits 132 ActivityClinician 182 ActivityType 232 Empty
33 EncounterDiagnosisSecondary 83 ActivityNet 133 ActivityStart 183 ActivityCode 233 Empty
34 EncounterDiagnosisSecondary 84 ActivityClinician 134 ActivityType 184 ActivityUnits 234 Empty
35 EncounterDiagnosisSecondary 85 ActivityStart 135 ActivityCode 185 ActivityNet 235 Empty
36 EncounterDiagnosisSecondary 86 ActivityType 136 ActivityUnits 186 ActivityClinician 236 Empty
37 EncounterDiagnosisSecondary 87 ActivityCode 137 ActivityNet 187 ActivityStart 237 Empty
38 EncounterDiagnosisSecondary 88 ActivityUnits 138 ActivityClinician 188 ActivityType 238 Empty
39 EncounterDiagnosisSecondary 89 ActivityNet 139 ActivityStart 189 ActivityCode 239 Empty
40 EncounterDiagnosisAdmitting 90 ActivityClinician 140 ActivityType 190 ActivityUnits 240 Empty
41 EncounterTransferSource 91 ActivityStart 141 ActivityCode 191 ActivityNet 241 Empty
42 EncounterTransferDestination 92 ActivityType 142 ActivityUnits 192 ActivityClinician 242 Empty
43 ActivityStart 93 ActivityCode 143 ActivityNet 193 ActivityStart 243 Empty
44 ActivityType 94 ActivityUnits 144 ActivityClinician 194 ActivityType 244 Empty
45 ActivityCode 95 ActivityNet 145 ActivityStart 195 ActivityCode 245 Empty
46 ActivityUnits 96 ActivityClinician 146 ActivityType 196 ActivityUnits 246 Empty
47 ActivityNet 97 ActivityStart 147 ActivityCode Requ1i9re7dActivityNet 247 Empty
48 ActivityClinician 98 ActivityType 148 ActivityUnits Requ1i9re8dA acst iovift yNColivneicmiabner 1254t8hEmpty
49 ActivityStart 99 ActivityCode 149 ActivityNet Non‐1M99anEdmaptotyry or not app2li4c9abElmepty
50 ActivityType 100 ActivityUnits 150 ActivityClinician 200 Empty 250 Empty
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Reliable Excellence in Healthcare
Required fields
The following fields are generally available and required as part of the record of an Encounter that has
ended and for which that Claim has been settled
Required fields*
FieldName Insurer Provider
1 PatientFirstName R R
2 PatientContactNumber ( R ) R
3 PatientBirthDate R R
4 PatientGender R R
5 PatientNationality R R
6 ClaimID ( R ) ( R )
7 ClaimIDPayer R ( R )
8 ClaimIDInvoice ( R ) R
9 ClaimPatientID R R
10 ClaimPayerID R R
11 ClaimProviderID R R
12 ClaimGross R R
13 ClaimPatientShare R R
14 ClaimNet R R
15 ClaimPaymentAmount R R
16 ClaimDateSubmitted R ( R )
17 ClaimDateReceived ( R ) R
18 ClaimDateSettlement R ( R )
19 ClaimDateSettlementReceived ( R ) R
20 ClaimDateLastTransaction R R
21 ClaimStatus R R
22 EncounterID ( R ) R
23 EncounterPatientID ( R ) R
24 EncounterFacilityID R R
25 EncounterStart ( R ) R
26 EncounterStartType ( R ) R
27 EncounterType ( R ) R
28 EncounterLocation ( R ) R
29 EncounterEnd ( R ) R
30 EncounterEndType ( R ) R
31 EncounterDiagnosisPrincipal ( R ) R
32 EncounterDiagnosisSecondary ( R ) R
*Required, when encounter has ended, and claim has been settled
( R ) Required if recorded by the Insurer or provider

Some patient data may be unavailable. For instance, some patients carry no form of identification and do
not know their Date of Birth and/or for instance they may not have a contact number.

Some fields may even have to remain empty, when the Encounter has ended and the Claim is settled
because the information can not be procured. These situations should decrease over time. For example
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