What Is A Clean Claim In Medical Billing?

4.3
What Is A Clean Claim In Medical Billing?
2 months ago

Clean Claim:

Medicare defines clean claim as a claim which has no defect, indecency or special circumstance, including incomplete documentation and reports that delays appropriate payment.

A clean medical claim is one that is verified and validated as an error-free claim and can be processed without additional information from the health care provider or a third-party payer. It is accurate from top to bottom. A clean medical claim comprises of the following criteria:

• The healthcare provider is officially licensed to practice medical services on the date of service and it is not under investigation for fraud.

• Every procedure code comprises an associative diagnosis code, which eradicates any issues regarding medical services. In addition, the form does not consist of expired or deleted codes.

• The patient’s coverage was in operation on the appointed date of service, and the patient’s insurance covers the service provided.

• The claim form includes all of the information including; patient name, address, date of birth, identification number, and group number that is required for a valid medical bill in the correct fields.

• The form correctly categorizes the payer and includes the valid payer identification number and mailing address.

• The claim is submitted at an appropriate time.

The American Medical Association (AMA) is the largest organization of physicians in the United States. This organization is dedicated to improving the quality of healthcare administration and health care facilities across the country. The current procedural technology (CPT) code set is sustained and revised by the AMA in accordance with the federal guidelines.

Additional clean claims elements:

Health care technicians review every claim submitted by medical domains, the whole information of the claim is validated and it is ensured that claim is 100% accurate complies with the payment standard to make a determination of proof of loss. Then it would be notified for the whole claim or some portion of the claim (that is being reviewed). The notice will identify the reviewed claim within the applicable prompt payment standard following receipt of the information that is required by the payment provider.

Clean claim submission:

Health care providers i.e. health professionals, health facilities, home health care providers or durable medical equipment providers, must plan a medical bill within a year soon after the date of treatment received by the patient for the clean claim.

Clean claim payment:

A clean claim must be issued and remove all known defects within 45 days after it is received by the health plan. The 45-day time period begins from the date the health plan informs a health care provider that the claim is erroneous.

Within 30 days after receipt of the claim, a health plan must notify the health care provider of all known reasons that prevent the claim from being a clean claim.

If a health plan determines that services mentioned on a claim are payable, the health plan shall pay for those medical services and shall not deny the entire claim because other services mentioned on the claim are erroneous.

After 45 days timeframe, the health professional, health facility, home health care provider or durable medical equipment provider cannot resubmit the same claim to the health plan.