Build Abu Dhabi Health Claim (DoH Shafafiya XML)

Skill: Convert a clinical encounter into a Shafafiya e-claim XML

Region: United Arab Emirates — Abu Dhabi (أبوظبي) Category: Health care — Department of Health Abu Dhabi (DoH) Does: Takes a clinical encounter and maps it onto the Shafafiya Claim.Submission XML for electronic submission to payers through the DoH Abu Dhabi Shafafiya / Riayati data-exchange platform. Spec: DoH Abu Dhabi Shafafiya data dictionary — Claim.Submission XML (ICD-10-CM diagnoses, CPT/HCPCS and Abu Dhabi drug/service codes)

Shafafiya is the Abu Dhabi counterpart to Dubai's eClaimLink (see build-dha-eclaim-xml): same data-in → e-claim-out shape, different emirate authority, code sets, and platform. Eligibility (Prior Request) and remittance (Remittance.Advice) follow the same schema family.

When this applies

• A licensed Abu Dhabi provider bills a payer (insurer/TPA) for an encounter under the DoH regulatory framework, after prior authorisation where required.
• The same envelope structure carries resubmissions (with a resubmission type and comment) and reconciles against the Remittance.Advice returned by the payer.

Structure (Claim.Submission → XML)

Header   SenderID (provider/clearinghouse license), ReceiverID (payer), TransactionDate,
         RecordCount, DispositionFlag
Claim (per claim):
   ID, IDPayer, MemberID, PayerID, ProviderID, EmiratesIDNumber
   Gross, PatientShare, Net
   Encounter:  FacilityID, Type, PatientID, Start/End, StartType/EndType
   Diagnosis (1..n):  Type (Principal/Secondary), Code (ICD-10-CM)
   Activity (1..n):   ID, Start, Type (CPT/HCPCS/Drug/Service), Code,
                      Quantity, Net, Clinician, PriorAuthorizationID
                      (Observation child rows where required)
   Contract / PlanID

Mapping & rules

• Identity — MemberID, PayerID, EmiratesIDNumber and ProviderID must match the member's policy and the DoH provider licence; ID/IDPayer uniquely key the claim.
• Coding — diagnoses in ICD-10-CM (one Principal + secondaries); activities in the correct Type with CPT/HCPCS or Abu Dhabi drug/service codes; quantities and units per the data dictionary.
• Amounts — Gross = Σ activity gross, PatientShare per the benefit (deductible/co-pay/co-insurance), Net = Gross − PatientShare; activity Net values must foot to the claim.
• Prior authorisation — carry PriorAuthorizationID on activities that required approval; encounter Type/StartType/EndType must be valid for the service.
• Envelope — RecordCount equals the number of claims; SenderID/ReceiverID route the file through Shafafiya/Riayati.

Worked example (outline)

Header SenderID=MF1234 (provider), ReceiverID=INS021 (payer), RecordCount=1
Claim ID=CLM-2026-0001, MemberID=…, EmiratesIDNumber=784-XXXX-XXXXXXX-X
  Encounter FacilityID=MF1234, Type=1 (outpatient), Start=2026-01-15
  Diagnosis Principal=J06.9 (ICD-10-CM)
  Activity Type=3 (CPT) Code=99213 Qty=1 Net=… Clinician=DOH-…
  Gross=…, PatientShare=… (20% co-insurance), Net=Gross−PatientShare

Emitted as a Shafafiya Claim.Submission XML and posted via the DoH platform.

Validation checklist

• Current Shafafiya data dictionary version; valid Claim.Submission structure
• Member/payer/provider IDs and Emirates ID match the policy and DoH licence
• Diagnoses in ICD-10-CM (one Principal); activities typed with CPT/HCPCS/Drug codes
• Gross / PatientShare / Net consistent; activity Nets foot to the claim
• PriorAuthorizationID present where required; encounter Type/StartType valid
• RecordCount matches claim count; SenderID/ReceiverID correct for routing
• Submitted via DoH Shafafiya / Riayati; reconciled against Remittance.Advice

Last updated: 2026-06-02 — the Shafafiya data dictionary, code sets, and Abu Dhabi drug/service lists change; confirm the current schema version, code sets, and submission rules against current DoH Abu Dhabi (doh.gov.ae / Shafafiya) guidance before use.