Medical billing is an administrative process that is necessary to manage a hospital’s smooth functioning. This process itself comprises multiple steps to improve the hospital’s efficiency by boosting its revenue cycle and improving medical care. It is important to note that three parties form an essential part of the medical billing cycle. These three parties are—the patient (first-party), health care provider (second party), and insurance company/payer (third party). As an independent administrative process, medical billing is necessary to share medical care information, payment, and reimbursem*nt details between the mentioned parties.
Sincemedical billing and collectionis associated with the reimbursem*nt and claims transmission process it is imperative to focus on the two types of claims that are associated with it.
There are two types of claims in medical billing.
Clean Claim:Medicare defines the term clean claim as “a claim that has no defect, impropriety, lack of any required substantiating documentation – including the substantiating documentation needed to meet the requirements for encounter data – or particular circ*mstance requiring special treatment that prevents timely payment”. A clean claim may refer to as a valid claim due to its role in the hassle-free process of making timely payment and enhancing the revenue cycle of the hospital. 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”.
In medical billing, a clean claim is the one that meets the following criteria.
- The health care provider has a valid license to practice medicine on the date of service. He/she isn’t involved in any fraud and isn’t undergoing investigation.
- The claims form should mention diagnosis code along with procedure code to substantiate the necessity of the medical treatment. Besides, deleted or expired codes are included in the claims form.
- The patient’s insurance must cover the procedure performed. Also, the coverage should be in effect on the date of service.
- The claims form must-have information like patient name, address, date of birth, identification number, and group number, etc.
- The claims form also must have a payer’s information like name, identification number, and mailing address.
- Timely submission of the claims form is indispensable.
FAQs
A clean claim is one that needs to be submitted without any discrepancies or other issues, such as inadequate evidence, that would impede payment. An increased Clean Claim Rate indicates that the information collected and analyzed within the electronic health record (EHR) is of high quality.
What are clean claims in medical billing? ›
Clean Claim: Medicare defines the term clean claim as “a claim that has no defect, impropriety, lack of any required substantiating documentation – including the substantiating documentation needed to meet the requirements for encounter data – or particular circ*mstance requiring special treatment that prevents timely ...
Which of the following would be considered a clean claim? ›
Clean claim defined: A clean claim has no defect, impropriety or special circ*mstance, including incomplete documentation that delays timely payment.
What is required for a clean claim for an established patient? ›
Clean claim definition
A clean claim meets all of the following requirements: Identifies the health professional, health facility, home health care provider or durable medical equipment provider who provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.
Can a clean claim be denied? ›
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.
What is not a clean claim? ›
A non-clean claim is defined as a submitted claim that requires further investigation or development beyond the information contained in the claim.
What is the difference between a clean claim and an unclean claim? ›
It should include all provider and member information, as well as records, additional information or documents to enable Security Health Plan to process the claim. A claim that does not meet the definition of a clean claim and requires investigation or additional documentation constitutes an unclean claim.
Which of the following is key to submitting a clean claim? ›
The three most important aspects of any medical claim include: Basic patient information, including full name, birthday, and address. The provider's NPI (National Provider Identifier) CPT codes that reflect the provided services.
How long does it typically take to receive payment with a clean claim? ›
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.
Why is it important to submit a clean claim? ›
Having a high clean claim rate indicates to insurance providers that the data you are collecting is high quality. It also shows that claim accuracy is something healthcare providers are paying attention to on the front end. If you submit a clean claim, it spends less time in accounts on the insurer's end.
To avoid eligibility rejections or denials, ensure the patient provides accurate information before or during registration and scheduling, obtain copies of the patient's insurance card, and try to avoid data entry errors. Also, verify dates of eligibility and benefit coverage, and obtain authorization when needed.
What is the difference between an EOB and an RA? ›
Recipient: The RA is sent to the healthcare provider or billing entity, whereas the EOB is typically sent to the patient or the policyholder.
What entity may be used to check claims and send clean them to a correct payer for each patient? ›
A clearinghouse checks the medical claims for errors, ensuring the claims can get correctly processed by the payer. Once clean claims are established, the claims and any associated medical records are sent electronically to all appropriate medical organizations.
What is the most common rejection in medical billing? ›
Common Reasons Medical Billing Claims Get Rejected
- Waited too Long to File the Claim. ...
- Proper codes are missing. ...
- The Insurance Company Lost the Claim, and then the Claim Expired. ...
- Patient Didn't acquire a Referral from a Physician. ...
- You Provided Two Services in One Day. ...
- You Ran Out of Authorized Sessions.
A clean claim meets all of the following criteria: Acknowledges the medical provider, health facility, residential healthcare provider, or provider of durable medical claims billing service who provided the service in considerable detail to verify affiliation status, if necessary, and includes any recognizing counts.
How does CMS define a clean claim? ›
The name for a person who has health care insurance through the Medicare or Medicaid Program. Clean Claims. 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.
What is considered a clean bill of health? ›
To “get a clean bill of health” is to be told by some authoritative source, generally a doctor, that one is perfectly healthy.
What common errors can prevent clean claims? ›
Common Pitfalls
- The health plan didn't receive the claim.
- A CPT code is missing or incorrect.
- Provider and/or patient identifiers are not included.
- The health plan information is incorrect.
- The plan does not cover the service.
