What Is A Clean Claim In Medical Billing

Over the past couple of years, the claim denials rate has drastically spiked, leading to major losses for both patients and healthcare providers. The medical staff working in the healthcare facilities put up great efforts in submitting a clean claim, free from errors.

After reviewing best practices in the top-notch medical billing companies in Texas, we can confidently say that submitting a clean claim is no big deal if all the processes are interlinked well and done vigilantly.

This guide details what a clean claim is and how to process it in medical billing. You will also gain insight into the common reasons for claim rejection.

What does it mean by a ‘clean claim’?

Simply put, a clean claim is an insurance claim free from errors like incomplete documentation that results in claim denials. A medical insurance claim becomes clean when checked for potential errors and gets accepted by the insurer with reimbursement for the rendered services. Two things make a claim clean; first, it has all the correct information. Second, it has no missing information.

How to make a clean claim?

As said previously, a claim will become clean if it has the correct and all the required information. The following fields must be filled accurately for a clean claim submission.

Accurate Claim Information:

A CMS-1500 form has several fields that must be carefully filled out to submit a clean claim. Failure to do that will result in claim rejection. Following are the details that must be filled out diligently and accurately.

• The facilities and healthcare professional information, including the service provider’s name, billing address, NPI, billing NPI, and billing tax id number.
• Patient’s or insurance plan subscriber’s details and their demographics
• If required, provide proof of the medical emergency or necessity as well as the appropriateness of the provided services.
• The date on which service was rendered and the place of service.
• If any prior authorization is required for certain services, obtain that beforehand.
• Use accurate diagnosis and procedural codes as well as suitable modifiers if needed.
• Additional information will be added based on the rendered services as required.

Additional Information:

There is some additional information that is often required to submit in order to prepare a clean claim. For instance, if the patient is a minor and covered by parents’ insurance, in that case, demographic information of the patient and the provider will be required. Here is a complete list of all the additional information required to file a clean claim:

• If the healthcare receiver is not a subscriber, the following information will be required from his/her end:

1. Other enrollees’ name is applicable in the CMS-1500 form if the patient is covered in multiple health benefit plans.
2. Group/policy number in the field 9a
3. Other enrollee’s date of birth in the field 9b
4. Other enrollee’s plan name (school, employer, etc) in the field 9c
5. Other enrollee’s HMO or provider name, if specified in the field 11d
6. The insurance subscriber’s plan name in field 11b

• Provide prior authorization number in the field 23 if required.
• If the amount is paid to the service provider through the insurer or subscriber, the amount paid field is applicable. A primary plan’s EOB may also be required.
• Balance due is applicable in field 30 if any outstanding balance is left.
• An anesthesia report must be attached to specify the time spent on anesthesia.
• The ambulance trip report must be submitted with the claim

Also Read: 7 Helpful Tips From An Experienced Nurse

What is an ideal clean claim rate?

Ideally, healthcare providers should achieve a 95% clean claim rate. That said, very few service providers reach this target. 75% to 85% is the common claim acceptance rate of the total they bill across various facilities. These figures show that almost 25% of the claim they submit is rejected due to some errors or missing information.

In fact, some recent studies found that the clean claim ratio has declined to 65%, as the rest 35% needs resubmission due to errors or incomplete documentation. This shows that healthcare providers lose $20 billion in reimbursement or delayed payments solely in the United States.

For a lucrative organization, you must not settle with a clean claim rate below 95%, and below 90% should be completely unacceptable. Although errors and omissions are bound to occur, anything more than a 5% claims rate costs your business both time and money. Therefore, experts say to set a high bar for a clean claim rate so that you can work toward your target and achieve profitability.

Improve clean claim rate – Tips by the best medical billing companies in Texas:

1. Keep patient’s records updated:

Whether it’s personal information or the insurer’s details, the patient’s information keeps changing. Therefore, it is advised to cross-check a patient’s information before rendering their service.

2. Verify patient’s eligibility before providing services:

Most claim rejections are due to outdated patient insurance information. To be closer to achieving a 95% of clean claim rate, you must check patients’ eligibility and confirm their primary, secondary, and tertiary insurances five days prior to providing them the services.

3. Keep detailed medical information:

Keeping detailed medical information will ensure a high clean claim rate. Having complete records of procedures, cases, medical history, and other similar information will work as supplemental records to file a claim.

4. Submit claims within the provided time frame:

Another key to achieving a high clean claim rate is submitting them in the provided time window. Closely pay attention to submission deadlines and set your target before the deadline so that if any issue comes up, it can be resolved before the deadline.

5. Cross-check modifiers:

Modifiers are crucial for claim submission. Double-check that you have assigned the right codes to each procedure; otherwise, it will result in rejection.

Conclusion:

While 100% is unpractical, a 95% clean claim rate is achievable. Optimize your services by keeping these clean claim submission tips in mind while filing a claim. This will surely help you maximize your clean claim rate and minimize claim denials.

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