Aiming for Clean claims in Optometry? Know how!



It is important for practices, including Optometry, to ensure submission of clean claims for capturing and increase timely revenues by identifying the causes for non-payment. It is essential that the staff is well-trained and possesses thorough knowledge of the billing and coding procedures of the Optometry practice.

 According to, A clean claim is defined as a claim that has no defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim. 

Submission of clean claims is crucial for avoidance of denials and rejections. Repeatedly, coding errors, omissions or incorrect information, and/or lack of verification leads to rejected or delayed payments. The entire claim settlement process is of submitting the claim, sorting data and finally rendering the payment. Few steps to clean claim processing are:

1. Data: One of the major steps is filling out the form CMS-1500 accurately and completely before submitting it to the claims processing system. Provide the correct ID numbers, patient and policy information, location of services, diagnosis codes, CPT and ICD codes, apt modifiers, create Local Coverage Determination linked to coding congruence, create National Correct Coding Initiative (NCCI) edits guidelines for apt modifiers and send it to the correct insurer.

2. Technology: For higher accuracy, claims should be filed electronically. This is also useful for contracting, payment of claims, and benefit quoting. Avoid paper filing and look towards receiving reimbursements by signing up for Electronic Funds Transfer.

3. Avoid Duplicate claims: It is important to be aware of services that are bundled into a single package; as this can help avoid duplicate claims. Be patient before filing a secondary claim.

4. Deadlines: To avoid definite rejections, submit the claims for reimbursements within the stipulated time. If extra information is required, it too should be submitted within the given time frame. Also, keep a buffer between filing of claims and deadlines to preserve time for eliminating errors. In case of denials, try resubmitting the claims within 3 days or ask for a response time of maximum one week.

5. Verification: Verify the patient entitlement and benefits with the insurance provider at least two days preceding the date of service. This should include policy dates, primary/secondary/tertiary insurance, medical coverage, in/out of network benefits, copays and deductibles, and procedure verification with regards to authorization and insurance coverage.

6. Documentation: It is imperative to maintain a copy of all records (procedures, services, medication) for processing claims.

7. Understand the system: Another best practice is to entirely understand CMS and insurance providers’ rules. Continuously monitor and analyze the denials and underpayments of failed claims and comprehend the vulnerable areas.

It is ideal to keep the claim percentage high for running a profitable optometry practice which comes from getting paid at the first submission. Ensure common goals and develop plans to resolve any fundamental issues.

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