• What is Claims?

    Notification to insurance company that payment of an amount is due under the terms of the policy. It is a request for payment of the contractual benefits by the insurer that is made by the insured or the beneficiary.

  • What is an E-claim?

    Electronic claim submission maximizes claims processing efficiency, any claim that can be submitted on paper can be submitted electronically in a form of program (XML) format.

  • What is E-claim Submission?

    Electronic claims program that allows providers to create a claim, validate it, and send it electronically directly from your practice management software Knowledge Engine for Health (KEH).

  • What is direct billing?

    Direct billing is an arrangement between a health insurance provider and a doctor (or other medical facility), where the doctor sends bills for services directly to your health insurance company. This means that you do not have to put in a separate claim with your insurance.

  • What is Medical Health Insurance?

    Insurance against loss by illness or bodily injury. Health insurance provides coverage for medicine, visits to the doctor or emergency room, hospital stays and other medical expenses. Policies differ in what they cover, the size of the deductible and/or co-payment, limits of coverage and the options for treatment available to the policyholder. Health insurance can be directly purchased by an individual, or it may be provided through an employer.

  • What is XML Sheet?

    Extensible Markup Language (XML) is a markup language that defines a set of rules for encoding documents in a format which is both human-readable and machine-readable.

  • What are claim types?
    • OP- Out patient
    • IP- In patient
    • DC- Day case
    • DL- Dental
    • PH- Pharmacy
  • What is TPA?

    A Third Party Administrator (TPA) is a person or organization that processes claims and performs other administrative services in accordance with a service contract, usually in the field of employee benefits.

  • What is policy?

    Policies define the roles and responsibilities of Providers, Professionals, Payers and the Regulator in the health system, and their interactions. Policies are arranged in four Policy Manuals:

    • Providers
    • Professionals
    • Payers
    • Regulator (in Abu Dhabi, HAAD is the unified healthcare sector regulator).
  • What is network?

    In network refers to providers or health care facilities that are part of a health plan's network of providers with which it has negotiated a discount/factor.

  • What is PBM?

    Pharmacy Benefit Management

  • What is Insurance Authorization?

    Decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary, also known as prior authorization, prior approval or precertification.

  • What is SPC?

    Standard Provider Contract – were in should have mutual agreement between provider and insurance.

  • What is Factor?

    It is also called multipliers or multiplication factor from basic price list of service adjudicate by HAAD as per SPC agreement / contract.

  • What is Discount?

    Percentage deducted from the agreed service price will become claim gross amount.

  • What is Patient Share / Co-patient share / Deductible?

    Amount of expenses that must be paid out of pocket before an insurer will pay any expenses.

  • What is the CPT code for simple dressing during the follow up period?

    Non-surgical cleansing of a wound without sharp debridement might be separately reimbursable using the appropriate service codes (51-01, 51-02 and 51-03); for the following services appropriate CPT codes must be used: wound debridement, dressing for burns, and dressing change under anesthesia.

  • Who is an established patient?

    An established patient has received professional services from the same physician or another physician in the same specialty and subspecialty in the same group practices, within the past three years.

  • Who is a new patient?

    A new patient is the one who has not received any professional services from the same physician or another physician in the same specialty and subspecialty in the same group practices, within the past three years.

  • What is the special rule in ER with reference to New and Established patients?

    In ER all patients considered as new patient.

  • What is DRG?

    Diagnosis related grouping

  • Which type of patient visit this DRG concept is applicable?

    It’s applicable for both inpatient and outpatient visits, however currently in Abu Dhabi it is being used only for IP admissions.

  • What is the CPT code for venipuncture and when this code is applicable?

    CPT code is 36415. Payment for Venipuncture shall be allowed only if an outside laboratory was utilized and the lab samples are drawn in a provider’s office.

  • What is modifier?

    Modifiers are two-character codes that add clarification and additional details to the procedure code’s original description, as listed in the main portion of the Current Procedural Terminology (CPT) book.

  • How many modifiers are currently mandated in Abu Dhabi?

    None of the modifiers are currently mandated in Abu Dhabi…

  • What is unbundling?

    Inappropriate billing of additional CPT codes that by definition these additional codes are already included in the reimbursement of the primary procedure.

  • What does CPT stand for?

    Current Procedural Terminology- is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.

  • What does ICD stand for?

    The International Classification of Diseases - is the standard diagnostic tool for epidemiology, health management and clinical purposes. ICD is used by physicians, nurses, other providers, researchers, health information managers and coders, health information technology workers, policy-makers, insurers and patient organizations to classify diseases and other health problems.

  • As per the adjudication rule code 14-01 dialysis considered as?


  • What does E&M stand for?

    Evaluation and Management - E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing.

  • What does DRG stand for?

    Diagnosis Related Group - a statistical system of classifying any inpatient stay into groups for the purposes of payment.

  • What does HCPCS stand for?

    HCPCS stands for Healthcare Common Procedure Coding System. A standardized coding system used to process claims for insurance payments.

  • What is Claims Resubmission?

    Resubmitting the claims by review and analyze the reasons of rejected payment for the claimed services with the help of denial codes provided by payer (Insurer) as per HAAD standard.

  • What is Claims Rejections?

    Claim or Services rejected from the payer or insurer by stating the submitted services are not eligible for the payment due to lack of information provided by the healthcare provider.

  • Who is Payer?

    Insurer an insurance company licensed by authority to provide health insurance services. Payer refers to insurance companies who reimburse the healthcare provider for the medical services rendered to their insured members.

  • What are the types of Rejections?

    Rejections are classified into two categories Administrative and Medical Rejections.

  • What is Remittance Advise (RA)?

    Remittance Advise is the summary of payment and rejections received from insurance companies for invoices submitted from the healthcare provider.

  • What is XML?

    Extensible Markup Language (XML) is a markup language that defines a set of rules for encoding documents in a format which is both human-readable and machine-readable.

  • How we are receiving RA?

    Receiving RA through HAAD post office (Green Rain Messenger) in xml format.

  • How we are submitting our resubmission files?

    Resubmission files are being uploaded through HAAD post office (Green Rain Messenger) in xml format.

  • What are the types of resubmission?
    • Correction
    • Internal complaint
    • Legacy
  • What does TPA stand for?

    Third Party Administrator – is an organization which processes claims as a separate entity it also administrates group insurance policies. They work with the employer as well as the insurer to communicate information between the two, as well as processing claims and determining eligibility.

  • Who is beneficiary?

    A person who receives benefits of any insurance plan or policy.

  • Who is Provider?

    A person or organization that provides medical services.

  • Why do patients have to show ID on each visit to the hospital?

    Our primary concern is for your health and safety. We request patient’s identification to ensure that we access and update the correct medical record. It’s also to protect the patient from fraud.

  • Why do patients need to bring insurance card for each visit?

    In order to file an insurance claim on patient’s behalf, it is necessary to make certain that we have the most current and accurate information about your insurance coverage and specific plan benefits.

  • Why is Registration necessary?

    Accurate registration benefits everyone, including patients/guarantors, providers and insurance companies during this process. Information in hospital records is confirmed or updated to ensure accurate claim submissions with insurance.

  • What’s the difference between insurance deductible, coinsurance, and copay?


    A deductible is usually a fix amount that patient have to pay out of own pocket before the insurance will cover the remaining eligible expenses. Depending on the insurance plan, the deductible can range from 0 AED all the way up to thousands.


    Coinsurance is usually a percentage, and represents the percentage cost that patient will need to pay and the insurance plan will pay towards eligible medical expenses. Some common coinsurance examples include: 100%, 80/20, 90/10 and 50/50 – so if patient have 80/20 coinsurance on insurance plan, it means that the insurance company will cover 80% of medical cost and patient is responsible for paying the other 20%. 

    Copay (copayment)

    Copays are similar to deductibles, in that it is usually a fixed amount of money patient have to pay each time when they are using their insurance.

    With most insurance plans, you will typically see some combination of deductible, coinsurance and copayments – or in some insurance plans may not have any of them. It will very much depend on specific insurance plan so be sure to check the policy details and let patient know what their out-of- pocket payments will be.

  • What is Non-Covered Services?

    Services for which an insurance policy will not provide payment. These services are to be paid by the patient at the time of service.

  • What if patient’s insurance company does not authorize or cover services?

    Patient will be responsible for charges your insurance company does not authorize or cover. It is recommended that you contact the ordering provider to discuss whether to receive the service and for other possible funding services.

  • What if a child needs Outpatient Surgery?

    A parent or legal guardian must accompany patients who are minors on the patient’s first visit. The accompanying adult is responsible for payment of the account.

  • What is coverage limits?

    Some health insurance policies only pay for health care up to a certain amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes have annual limit. In these cases, the health plan will stop payment when they reach the benefit maximum and the policy-holder must pay all remaining costs.