Guidelines to Submit a Clean Claim

Defining Clean Claim 

A clean claim is a submitted claim without any errors or other issues, including incomplete documentation that causes claim rejections or denials. As per the definition of a clean claim first part is correct to claim information and while the second part is not missing any information.

In this blog, we shared guidelines to submit clean claims which include discussing both components i.e., correct information and not missing any information.

Accurate Claim Information

There are several required fields on CMS-1500 for a clean claim, and the claim will get denied if elements are inaccurate. A clean claim should include the accurate entry of the following information:

• Details for health care professional, facility information which includes rendering provider name and NPI, billing address, billing NPI, billing tax id number. 
• Details about patient or insurance plan subscriber, patient and/or subscriber insurance details, and demographics.
• Date of service and place of service.
• If necessary, substantiates the medical necessity and appropriateness of the service provided.
• If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.
• Accurate use of procedural codes, diagnosis codes, and suitable modifiers if required.
• Additional documentation based upon services rendered as reasonably required by the health plan.

Additional information

There are some insurance details that are not required while every claim. For example, the patient is a minor and he has insurance coverage from his parents.

In this case, demographics information of patients, as well as insurance subscriber, will be required. So, list of such additional information required to submit a clean claim is discussed below:

• If the patient is not a subscriber, then the following details are required:
  • Other insured’s or enrollee’s name (CMS-1500, field 9), is applicable if a patient is covered by more than one health benefit plan. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
  • policy/group number (CMS-1500, field 9a)
  • Other insured or enrollee date of birth (CMS-1500, field 9b)
  • Other insured or enrollee plan name (employer, school, etc.) (CMS-1500, field 9c)
  • Other insured or enrollee HMO or insurer name. If the essential data element specified in CMS-1500, field 11d
  • Subscriber’s plan name (employer, school, etc.) (CMS-1500, field 11b)
• Prior authorization number (CMS-1500, field 23), is applicable when prior authorization is required
• Whether the assignment was accepted (CMS-1500, field 27), is applicable when the assignment has been accepted
• Amount paid (CMS-1500, field 29), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber, or by a primary plan (Commercial or Medicare). When applicable, a copy of the primary plan’s EOB is required
• Balance due (CMS-1500, field 30), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber
• Ambulance trip report, submitted as an attachment to the claim
• An anesthesia report is applicable to report time spent on anesthesia services.

To submit a clean, health care providers must bill the insurance companies within one year after the date of service or date of discharge, then only the claim will be considered a clean claim. If Insurance companies rejected or denied the claim, they will reply within 30 days after claim submission.

You will reply with denial codes i.e., exact reasons why the claim is been rejected. If your claim submission is error-free and insurance accepts it, they will provide reimbursement within 30 days and will provide payment details in terms of EOBs (Explanation of Benefits) or ERAs (Electronic Remittance Advice). 

Most practices struggle with submitting a clean claim as providers are busy inpatient care and can’t provide more attention to medical billing.

A high number of claim rejections and denials will directly affect your practice revenue. Medical Billers and Coders can assist you in submitting a maximum number of clean claims with help of specialty-wise billing and coding experts.

For all our clients, we managed to have a clean claim percentage of 95%. To know more about our clean claim submission services contact us at  info@medicalbillersandcoders.com/  888-357-3226

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