InsureOS — Every claim, adjudicated and paid.

eClaimLink · Dubai

Since 1 January 2013, every claim in Dubai goes to the insurer or TPA electronically through DHA’s eClaimLink, and each licensed facility claims on its own facility ID. The Dubai Health Insurance Corporation’s Claims Management Policy Directive took effect on 16 November 2025. It replaced the earlier claims rules and covers pre-authorisation, submission, adjudication, remittance with denial codes, settlement and reconciliation.

Source: DHA Circular 35/2012, 4 Dec 2012 · Al Tamimi & Co. summary of the 2025 directive, 31 Oct 2025

Shafafiya · Abu Dhabi

DoH requires licensed entities to use electronic person-register, claim and remittance transactions only. Shafafiya’s data dictionary defines the claim submission, remittance advice, prior request and prior authorisation schemas a payer exchanges with providers. From 1 January 2027, the Abu Dhabi Outpatient Classification (ADOC) becomes the main way outpatient care is reimbursed. Shadow billing through Shafafiya started on 1 July 2026.

Source: HAAD/DoH Data Standard, rev. 14 Apr 2014 · Shafafiya dictionary · DoH Circular 76/2026, 14 May 2026

Riayati e-Claims Post Office · northern emirates

For MOHAP-regulated facilities, the e-Claims Post Office inside Riayati carries the whole claim workflow between facilities and insurers: eligibility and coverage checks, prior authorisation, claim submission, payment information and denials. Everything runs on one coding set. MOHAP reported 40 insurers and more than 1,000 facilities linked by October 2022.

Source: MOHAP, 10 Oct 2020 · MOHAP, 11 Oct 2022

Prior authorisation

In Dubai, under the 2025 directive as Al Tamimi summarises it, the provider requests prior authorisation within one hour of the physician’s order. The insurer or TPA answers within six hours for elective outpatient care, within 24 hours for elective inpatient care, and immediately for an emergency. In Abu Dhabi, prior requests and authorisations are Shafafiya transactions. In the northern emirates, they run through the Riayati Post Office.

Source: Al Tamimi & Co., 31 Oct 2025 · Shafafiya dictionary

Coding and claim standards

DHA requires ICD-10-CM for diagnoses, CPT-4 for procedures, HCPCS Level II for supplies and CDT for dental work. It also requires the Dubai Drug Code for medicines and LOINC for observations. DoH defines its code sets in the Shafafiya data dictionary and holds emirate-wide licences for them. Where two codes fit, the provider uses its default standard, so a dentist uses dental codes and a surgeon uses CPT. DoH also publishes Claims and Adjudication Rules on Shafafiya.

Source: DHA coding standard v2, effective 3 Nov 2023 · HAAD/DoH Data Standard, rev. 14 Apr 2014

Payment and resubmission

In Dubai, according to the same summary, payment is due within 45 days for an initial claim and 30 days for a resubmission. A disputed claim can be resubmitted twice. Insurers and TPAs may not charge providers registration, administration or platform fees. Fines run from AED 10,000 to AED 50,000 per incident.

Source: Al Tamimi & Co., 31 Oct 2025

AI-assisted adjudication

The workbench proposes a settlement — PhilHealth case rate, senior/PWD discount, VAT exemption and co-pay — while an AI assistant scores confidence, validates documents and checks ICD-10 consistency. The adjudicator decides; the math is done.

OCR intake & document audit

Claims arrive from web, mobile photo or partner API. OCR extracts fields with a confidence score, verifies BIR official receipts and indexes ICD-10 — low-confidence values flagged before adjudication.

Clinical pre-authorization

Medical, dental and veterinary LOA requests in one queue with urgency and aging trackers — plus pluggable clinical decision support, so reviewers approve the right cases first, on guideline.

Coordination of benefits

Determine payer sequencing, apply PhilHealth-first offsets and calculate residual member liability for multi-coverage claims — duplicate and secondary-payer logic built in.

Fraud, waste & abuse detection

Every finding is scored — duplicate claims, excessive frequency, provider outliers — and routed for investigation before a single peso goes out the door.

Finance, WHT & reconciliation

Settle approved claims against the corporate escrow balance with BIR withholding tax per payee, bulk disbursement over PESONet, and carrier-funds reconciliation — every statement audit-ready.

Member self-service

Members request cashless LOAs, file reimbursement claims with their receipts, and track every Explanation of Benefits — with appeals — from an installable web app, no app store needed.

Provider & corporate portals

Providers submit direct billing, GOP and inpatient claims with WHT auto-calculated; corporate HR runs enrollment and roster; carriers watch program performance — each in its own workspace.

Workflow rules & SLA engine

Configure adjudication rules, auto-adjudication thresholds, escalations and SLA clocks without a developer — and watch turnaround and queue metrics in operational dashboards.

RBAC, MFA & audit reporting

Nineteen role-scoped workspaces, MFA enforcement and an access-control console — consolidating logs, overrides, exceptions and policy deviations into regulator-ready compliance reports.