What is a clean claim in insurance?
(ii) Clean claim defined In this paragraph, the term “clean claim” means a claim that has no defect or impropriety (including any lack of any required substantiating documentation) or particular circ*mstance requiring special treatment that prevents timely payment from being made on the claim under this part.
“A clean claim is one that must be submitted with no inconsistencies or other factors, such as insufficient documentation, that would prevent payment.” A clean claim requires numerous elements, and medical bills are turned down if any of these elements are unaccounted, incomprehensible, or inaccurate.
To file a clean claim, the hospital may outsource medical billing services from a reputed medical billing company. Dirty Claim: The term dirty claim refers to the “claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment”.
Clean Claims are claims that have all information in them and nothing is missing. If any mandatory or conditional information is missing, the claim will be considered unclean. Examples of unclean claims include invalid member ID, provider data discrepancy NPI and atax ID does not match.
”clean claim is an insurance claim that was successfully processed and reimbursed the first time it was submitted. This means no errors, rejection, or need for manual input of additional information. Having a high clean claim rate indicates to insurance providers that the data you are collecting is high quality.
While incorrect coding in a claim will almost certainly lead to denial, coding itself is only one piece of the clean claims puzzle. Administrative deficiencies can also lead to denied claims. It's strategically important to take a holistic approach to claims management that prioritizes clean claim submission.
Non-clean Claim A Non-clean Claim is a claim submitted to the health plan that requires further investigation or development beyond the information contained on the claim submitted for adjudication.
These laws typically require the company to pay within 30 days of receiving a “clean claim” that contains all of the information that the payer needs to process the claim.
A clean claim is one that does not require the Medicare Administrative Contractor (MAC) to investigate or develop external to their Medicare operation on a prepayment basis.
A "clean claim" means a claim that does all of the following: Identifies the health professional, health facility, home health care provider, or durable medical equipment provider that provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.
How do clean claims impact healthcare organizations?
A high clean claims rate is essential for healthcare providers and billing organizations because it can lead to faster reimbursem*nt, reduced administrative costs associated with claim resubmissions and appeals, and improved cash flow.
In its simplest form, a clean claim should be defined as one that has no errors or omissions and can be processed without additional information or verification of information by a human, third-party service, or automation.
Claims that do not meet the definition of “clean” claims are “other-than-clean” claims. “Other-than-clean” claims require investigation or development external to the contractor's Medicare operation on a prepayment basis.
Flawed medical coding and billing add extra administrative costs. Faulty payment claims come back to medical practice with objections, and which requires extra time and resources to eliminate those errors and submit the bills again. It only delays the payment process but also adds additional follow-up costs.
The claim offers unique medical codes, or CPT (Current Procedural Terminology) codes, that reflect the services rendered during the patient's visit. When a provider submits a clean claim or an error-free claim, the claim moves through accounts receivable quickly and payments occur quicker.
Most common rejections
Duplicate claim. Eligibility. Payer ID missing or invalid.
The industry standard benchmark for Clean Claim Rate is 95%. This means that healthcare organizations should aim to have at least 95% of their claims processed without errors or rejections.
Incorrect, Incomplete, or Unsupported Claim
Claims are often denied due to technicalities. Failure to file a timely claim, failure to notify the appropriate parties (such as employers), or failure to follow other rules may lead to an unnecessary claim denial.
The insurance representative does not need to know every little detail of your life after the accident. Don't discuss information about your family, your job, past accidents, past injuries, and anything that is not strictly relevant to your accident injury claim. Also, don't answer questions that haven't come up.
If the claim is determined to be “unclean” or contested, follow the carrier's instructions for resubmitting the claim along with any missing or corrected information.
What is a no pay claim?
Special Billing Situations
In some cases, Medicare requires you to submit a claim even though you do not expect payment (no-pay claim).
Once the claim is processed, you will receive an Explanation of Benefits (EOB) (also known as COB) that details how the care you received was paid by your plan. You may also receive a bill from your doctor during this time for any charges left unpaid by you or your insurance company.
Invalid Claim or “Rejected Claim” means the rejected Claim or the Claim deemed invalid by the Claims Administrator at the end of or during the claims processing process provided for in the Final Settlement Agreement and which will not be entitled to compensation provided for in the Final Settlement Agreement; Sample 1.
It takes time for each person to do his or her job, complete paperwork, and pass the claim to the next person. If one party takes too long or makes a mistake, it can prolong the response process. The response time for your claim could be as little as a few days or as long as multiple months depending on the situation.
Allowed Amount – This is the maximum payment the plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
