Billing & Claims Management Master Data & Configuration

Master Data Inventory

Note: Payers, insurance plans, contracts, and fee schedule items are mastered in policy-contract-mgmt and referenced here via foreign keys.

Setup Sequence

The following dependency order ensures that billing and claims logic, mappings, and workflows function correctly from day one.

Narrative Load Order

1. Shared foundations (from other modules): facilities, departments, users, payers, insurance plans, contracts, fee schedule items.
2. MD-BIL-016 POS locations & cash drawers.
3. MD-BIL-011 UAE emirate & VAT configuration.
4. MD-BIL-008 financial class codes.
5. MD-BIL-007 & MD-BIL-015 payment method types and refund reason codes.
6. MD-BIL-010 UAE payer identifiers & profiles (aligned with Policy & Contract Mgmt).
7. MD-BIL-002 & MD-BIL-005 revenue codes and modifier codes.
8. MD-BIL-001 charge description master (CDM) — depends on revenue codes, modifiers, fee schedules, contracts.
9. MD-BIL-009 claim submission channels — depends on payer profiles.
10. MD-BIL-003 & MD-BIL-004 adjustment and denial reason codes.
11. MD-BIL-006 & MD-BIL-014 claim edit rules and collection worklist queues.
12. MD-BIL-012 self-pay discount & charity policies.
13. MD-BIL-013 patient statement templates (EN/AR, VAT wording, PDPL notices).

Master Data Specifications

MD-BIL-001: Charge Description Master (CDM)

Purpose

Central catalogue of all billable services (procedures, labs, imaging, room & board, supplies) used for charge capture and claim line generation. Each CDM item maps to CPT/HCPCS, ICD-10-AM where relevant, revenue code, and contracted fee schedule items from policy-contract-mgmt. Critical for automated charge capture (WF-BIL-001) and claim generation (WF-BIL-002).

Logical Schema

Table: charge_description_master

Sample Data

Data Governance

• Owner: Revenue Cycle Manager
• Contributors: Coding Team, Finance, Department Heads
• Approval: CDM Committee (Finance + Clinical + Coding)
• Update Frequency: Annual full review; incremental updates with CPT/ICD-10-AM changes or new services.
• Change Process: 1. Department submits CDM change request (new service or price change). 2. Coding validates CPT/HCPCS, ICD-10-AM, revenue code mapping. 3. Finance validates pricing and VAT treatment (per UAE FTA rules). 4. RCM approves and IT updates in test environment. 5. Parallel pricing validation vs contracts; then promote to production. 6. Notify impacted modules (CPOE, RIS, LIS, PIS, scheduling).

Validation Rules

• cdm_code unique per facility.
• display_name_en and display_name_ar mandatory and non-empty.
• base_charge_amount > 0.
• If vat_applicable = TRUE, vat_rate must be > 0 and <= 100.
• effective_date <= expiry_date (if expiry set).
• revenue_code must exist in revenue_codes.
• If cpt_code present, must be valid CPT format (regex [0-9]{5} or alphanumeric HCPCS).
• If doh_service_code / dha_service_code present, must match payer directory formats.

MD-BIL-002: Revenue Codes

Purpose

Standard revenue codes used to classify services on institutional claims and for internal reporting (e.g., room & board, lab, radiology). Used by CDM and claim line generation.

Logical Schema

Table: revenue_codes

Sample Data

Data Governance

• Owner: Billing Manager
• Source: NUBC revenue code set; local payer-specific subsets.
• Approval: Billing Manager + Finance.
• Update Frequency: When NUBC updates or UAE payers introduce new mappings.
• Change Process:
• Monitor NUBC and payer circulars.
• Evaluate impact on CDM and claims.
• Update codes and test claim generation.

Validation Rules

• revenue_code must be 3–4 digits.
• display_name_en/display_name_ar required.
• effective_date must not be in the future for active codes.
• Codes used in CDM cannot be inactivated without migration plan.

MD-BIL-003: Adjustment Reason Codes

Purpose

Standardised codes for payment adjustments during posting (contractual write-offs, discounts, non-covered services). Used in payment_allocations, claim_responses, and AR reporting.

Logical Schema

Table: adjustment_reason_codes

Sample Data

Data Governance

• Owner: Billing Manager
• Approval: Finance Manager for GL mapping; RCM for usage rules.
• Update Frequency: With X12 CARC/RARC updates and payer circulars.
• Change Process:
• New CARC/RARC from payer → add mapping.
• Facility-specific codes → require finance + RCM approval.

Validation Rules

• adjustment_code unique.
• financial_impact_type must be one of controlled list.
• Facility-defined codes must start with FAC- (enforced by regex).
• Cannot inactivate codes in use in open AR without migration.

MD-BIL-004: Denial Reason Codes

Purpose

Categorised denial reasons for claims and claim lines, used for denial management (WF-BIL-006) and analytics (INT-BIL-006).

Logical Schema

Table: denial_reason_codes

Sample Data

Data Governance

• Owner: Denial Specialist Lead
• Approval: Revenue Cycle Manager.
• Update Frequency: As payer denial patterns change; at least quarterly.
• Change Process:
• New denial from ERA → map to existing or create new code.
• Review categories quarterly for analytics consistency.

Validation Rules

• denial_code unique.
• category must be from controlled list.
• If is_appealable = FALSE, standard_appeal_days must be NULL or 0.
• If payer_id set, payer_specific_code must be non-null.

MD-BIL-005: Modifier Codes

Purpose

CPT/HCPCS modifiers used to refine procedures (e.g., professional vs technical, bilateral). Used in CDM, charge capture rules, and claim lines.

Logical Schema

Table: modifier_codes

Sample Data

Data Governance

• Owner: Coding Team Lead
• Approval: Coding Committee.
• Update Frequency: Annually with CPT/HCPCS updates.
• Change Process:
• Import updated modifier list.
• Validate against payer policies (DHA/DOH circulars).

Validation Rules

• modifier_code 2–5 characters.
• Cannot inactivate modifiers used in active CDM without remediation.
• allowed_for_facility_claims OR allowed_for_professional_claims must be TRUE.

MD-BIL-006: Claim Edit Rules

Purpose

Configurable rules that validate claims before submission (WF-BIL-002), including CCI edits, payer-specific rules for DHA eClaimLink and DOH eClaims, and facility policies.

Logical Schema

Table: claim_edits

Sample Data

Data Governance

• Owner: Revenue Cycle Manager + IT RCM Analyst.
• Approval: RCM Committee; for payer-specific rules, payer circulars.
• Update Frequency: Quarterly; ad-hoc for payer changes.
• Change Process:
• Rule request documented with test cases.
• Build and test in non-production with sample claims.
• Monitor impact (denial rate, clean claim rate).

Validation Rules

• edit_code unique.
• severity and action from controlled lists.
• If payer_specific = TRUE, payer_id or submission_channel_code must be set.
• rule_logic_json must be valid JSON and schema-validated.

MD-BIL-007: Payment Method Types

Purpose

Standard list of accepted payment methods for patient and payer payments (WF-BIL-004, WF-BIL-005, WF-BIL-007).

Logical Schema

Table: payment_method_types

Sample Data

Data Governance

• Owner: Finance Manager
• Approval: CFO / Finance Director.
• Update Frequency: Rare; when new channels added.
• Change Process:
• Finance approves new method.
• IT configures integration (e.g., payment gateway).

Validation Rules

• payment_method_code unique.
• category from controlled list.
• If requires_reference_number = TRUE, UI must enforce reference entry.

MD-BIL-008: Financial Class Codes

Purpose

High-level grouping of accounts for reporting and workflow (insured, self-pay, government, VIP). Used in AR dashboards and collection strategies.

Logical Schema

Table: financial_class_codes

Sample Data

Data Governance

• Owner: Revenue Cycle Manager
• Approval: Finance Director.
• Update Frequency: Rare.
• Change Process:
• Changes coordinated with Policy & Contract Mgmt and reporting teams.

Validation Rules

• financial_class_code unique.
• Cannot inactivate classes used by active encounters without migration.

MD-BIL-009: Claim Submission Channels

Purpose

Defines how claims are submitted to each payer (DHA eClaimLink, DOH eClaims, direct portal, paper). Used in WF-BIL-003 and integration routing (INT-BIL-004, INT-BIL-005).

Logical Schema

Table: claim_submission_channels

Sample Data

Data Governance

• Owner: IT/RCM Integration Lead
• Approval: CIO + RCM.
• Update Frequency: As payer connectivity changes.
• Change Process:
• Update endpoint URLs, credentials, and mapping with eClaimLink/DOH.

Validation Rules

• channel_code unique.
• channel_type from controlled list.
• For DHA_ECLAIM and DOH_ECLAIM, endpoint_url must be set.

MD-BIL-010: UAE Payer Identifiers & Profiles

Purpose

Augments shared payers with UAE-specific identifiers and attributes needed for billing, such as DHA payer codes, DOH Shafafiya IDs, and emirate coverage.

Logical Schema

Table: payer_profiles

Sample Data

Data Governance

• Owner: Policy & Contract Manager
• Approval: RCM + IT Integration.
• Update Frequency: Monthly or when payer list changes.
• Change Process:
• Sync with DHA/DOH payer registries.
• Validate codes with eClaimLink/DOH test submissions.

Validation Rules

• payer_id must exist in payers.
• At least one of dha_payer_code or doh_payer_code must be present for insured payers.
• default_submission_channel_code must be compatible with emirate coverage.

MD-BIL-011: UAE Emirate & VAT Configuration

Purpose

Defines emirate-level configuration and VAT applicability for billing, ensuring compliance with UAE Federal Tax Authority (FTA) rules.

Logical Schema

Table: emirate_vat_config

Sample Data

Data Governance

• Owner: Finance Manager
• Approval: CFO.
• Update Frequency: As FTA regulations change; at least annual review.
• Change Process:
• Legal/Tax advisor review.
• Finance updates configuration and communicates to RCM.

Validation Rules

• vat_rate_standard between 0 and 100.
• last_review_date cannot be in the future.

MD-BIL-012: Self-Pay Discount & Charity Policies

Purpose

Defines discount and charity care rules applied to self-pay or partially insured patients, used in patient billing workflows (WF-BIL-005).

Logical Schema

Table: discount_charity_policies

Sample Data

Data Governance

• Owner: Finance Manager
• Approval: Charity/Discount Committee; CFO.
• Update Frequency: Annually.
• Change Process:
• Policy review with legal and compliance (including PDPL considerations for financial hardship documentation).

Validation Rules

• discount_value > 0 and <= 100 for PERCENT.
• Policies must not conflict with payer contracts (verified with Policy & Contract Mgmt).

MD-BIL-013: Patient Statement Templates

Purpose

Defines templates for patient statements (EN/AR, layout, PDPL notices, payment instructions) used in WF-BIL-005 and INT-BIL-007.

Logical Schema

Table: patient_statement_templates

Sample Data (metadata)

Data Governance

• Owner: Patient Billing Manager
• Approval: RCM + Legal (for PDPL wording).
• Update Frequency: Annually or branding change.
• Change Process:
• Update HTML in test.
• Validate placeholders and bilingual content.

Validation Rules

• html_body must include mandatory placeholders for statement number, due date, total amount, PDPL privacy notice.
• Only one template per facility can be is_default = TRUE.

MD-BIL-014: Collection Worklist Queues & Priorities

Purpose

Defines AR follow-up queues and prioritisation rules for WF-BIL-006 and AR dashboards.

Logical Schema

Table: collection_queues

Sample Data

Data Governance

• Owner: AR Manager
• Approval: RCM.
• Update Frequency: Quarterly.
• Change Process:
• Adjust thresholds based on AR performance KPIs.

Validation Rules

• priority must be between 1 and 9.
• Ranges (aging_min_days, aging_max_days) must not overlap for same target_type in active queues.

MD-BIL-015: Refund Reason Codes

Purpose

Standard reasons for patient and payer refunds, used in refunds table and finance workflows.

Logical Schema

Table: refund_reason_codes

Sample Data

Data Governance

• Owner: Finance Manager
• Approval: CFO for new categories.
• Update Frequency: Rare.
• Change Process:
• Ensure mapping to GL accounts and audit trails.

Validation Rules

• refund_reason_code unique.
• category from controlled list.

MD-BIL-016: POS Locations & Cash Drawers

Purpose

Defines physical and virtual POS locations and associated cash drawers for WF-BIL-007 and cashier screen SCR-BIL-009.

Logical Schema

Table: pos_locations

Sample Data

Data Governance

• Owner: Cash Office Supervisor
• Approval: Finance Manager.
• Update Frequency: On opening/closing of locations.
• Change Process:
• Coordinate with Facilities and IT for device mapping.

Validation Rules

• pos_code unique.
• is_cash_drawer = TRUE only for physical locations.

Configuration Parameters

Data Load Procedures

Initial Load

1. Source Identification - CDM: existing billing system exports (CSV/Excel), finance price lists. - Revenue codes, modifiers, CARC/RARC: vendor or standards body files. - Payer profiles: DHA/DOH payer lists, Policy & Contract Mgmt. - VAT/emirate config: finance/legal documentation.

2. Format & Import - Preferred formats: CSV or UTF-8 encoded Excel; JSON for rules (claim_edits). - Import staging tables:

   • stg_charge_description_master
   • stg_revenue_codes
   • stg_modifier_codes
   • stg_adjustment_reason_codes
   • stg_denial_reason_codes
   • stg_payer_profiles
   • Use ETL scripts to transform and load into production tables after validation.

3. Validation on Import - Referential integrity:

   • revenue_code exists in revenue_codes.
   • financial_class_code exists in financial_class_codes.
   • payer_id exists in payers.
   • Code format checks (CPT, revenue codes, modifiers).
   • Duplicates detection on key fields (e.g., cdm_code, revenue_code).
   • VAT consistency with emirate_vat_config.

4. User Acceptance - Parallel run: generate sample claims and compare with legacy system outputs. - Validate DHA/DOH test submissions using eClaimLink/Shafafiya sandboxes.

Ongoing Synchronization

• Standards Updates
• Annual CPT/HCPCS, ICD-10-AM, modifier updates:
  • Import new codes into staging.
  • Map to existing CDM and claim edits.

• CARC/RARC updates:

  • Import and reconcile with adjustment_reason_codes.

• Payer & Contract Changes

• Integration with policy-contract-mgmt:

  • When new contracts or fee schedules are added, update CDM fee_schedule_item_id mappings.
  • Update payer_profiles and claim_submission_channels as needed.

• Governance & Audit

• All changes logged with created_by, updated_by, timestamps.
• Periodic audits to ensure inactive codes are not used in new transactions.

Import/Export Formats

• CSV
• Used for bulk CDM, revenue codes, modifiers, reason codes.
• UTF-8 encoding to support Arabic descriptions.
• JSON
• Used for claim_edits.rule_logic_json and configuration exports.
• API
• Internal APIs to sync payer profiles and fee schedules from policy-contract-mgmt.
• FHIR-based APIs (INT-BIL-007) for patient balance exposure to Patient Portal.

Error Handling & Reporting

• Validation errors written to master_data_import_errors with:
• dataset_id, record_identifier, error_code, error_message.
• Import summary reports:
• counts of inserted, updated, rejected records.
• No partial commit for a dataset: use transactional imports per dataset to ensure consistency.

This specification provides the master data and configuration foundation required for the Billing & Claims Management module, aligned with UAE regulatory and payer environments and supporting all defined workflows (WF-BIL-001 to WF-BIL-007). ```