Clean Claim
A clean claim is a claim that complies with all standard coding guidelines, contains no missing information, and is free of any potential defect or impropriety.
What is a Clean Claim?
A clean claim is a healthcare claim that contains complete and accurate documentation, enabling healthcare providers to receive timely reimbursement without delays caused by requests for additional information or corrections. This means the claim data must be consistent across all fields, including patient information, provider details, and services rendered. All necessary forms, medical records, and supporting evidence must accompany the claim, and diagnosis and procedure codes must be correctly applied according to the latest coding standards. Additionally, the claim must meet the specific submission guidelines and policies of the insurer or health plan.
This type of claim accelerates revenue flow and improves cash management for healthcare organizations. Clean claims are paid faster, often within 45 days after receipt by the health plan, and they reduce administrative burden by avoiding claim rejections and resubmissions, which saves time and resources. Utilizing software tools, such as claim scrubbing tools or Clean Claims platforms, can automatically check claims against payer rules and coding standards to identify and correct errors before submission.
What is the difference between a Clean Claim and Rejected Claim?
A clean claim is complete and accurate, leading to timely reimbursement and reduced administrative burden. A rejected claim, in contrast, is incomplete or inaccurate, causing delays in payment and requiring additional effort for correction and resubmission.
A clean claim contains complete and accurate documentation, while a rejected claim lacks complete or accurate information.
Clean claims enable timely reimbursement and faster revenue flow, often paid within 45 days. Rejected claims cause delays in reimbursement due to requests for additional information or corrections.
Clean claims reduce administrative burden by avoiding rejections and resubmissions. Rejected claims increase administrative burden due to the need for corrections and resubmission.
Clean claims meet specific submission guidelines and policies, with correctly applied diagnosis and procedure codes. Rejected claims fail to meet these standards or contain coding errors.
Utilizing software tools can help identify and correct errors in claims before submission to ensure they are clean. Rejected claims are those that have failed these checks or were submitted with errors.
What are examples of a Clean Claim?
A hospital submits a claim for a patient's appendectomy, including all necessary patient demographics, correct CPT and ICD-10 codes, and a detailed operative report, leading to quick payment from the insurer.
A primary care physician's office uses claim scrubbing software before submission, which identifies a missing modifier on a procedure code. After correction, the claim is submitted and processed without delay.
An ambulance service submits a claim with complete documentation of the transport, including pickup and drop-off locations, patient condition, and medical necessity, resulting in timely reimbursement.
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