Clean Claim

Clean claim refers to the process of making sure that a claim has everything needed for it to be processed at first submission. That should be the goal for every great medical biller – first time, every time.

Now this is not always easy because how a CMS 1500 claim form is completed will differ. Every carrier is different and what they expect the claim to look like can vary. Some carriers want minimal information on the claim form while others require that almost every field on the form have some data. 

Remember, a claim tells a story about the patient and nobody likes to have pages of the story missing. We all want to know the when, where, why, what and how in every story and claim billing is really no different.

A Clean Claim Includes:

  • Who is the patient?
  • Where does the patient live?
  • Who is the provider that performed the service?
  • Where is the provider located?
  • What health plan information does the patient have?
  • What services are being performed?
  • When was the visit?
  • Why is the patient being seen?
  • How old are they?
  • How much did the visit cost?
  • What modifier do I need to bill?
  • What documentation should accompany the claim?
  • What are the correct codes?

All of these questions, if answered correctly on your billed claim, should result in this claim moving through the insurance process without being held, rejected or denied. 

How to Ensure that Your Claim is Clean?

  • Do your homework. Find out what the health carrier requires before your first claim is submitted. You can call the health carrier or go online at the carrier’s website.
  • The first instinct, when a claim is not paid, is to simply rebill it. Don’t! Call the carrier first and find out exactly why the claim was not paid.
  • Make yourself a billing manual that includes all of the special tips and tricks you have learned, by trial and error. This will include billing address changes, special modifiers, special instructions, etc. This way you don't have to reinvent the wheel when you are faced with a claim issue.

So where did the term clean claim come from? I am not sure who coined the phrase but I am guessing it was a health insurance carrier. Health carriers are quick to proclaim that the primary reason that claims are denied or paid correctly is due to billing errors.

From Experience

When account receivables starts to rise, everyone takes notice and the common assumption is that either:

1.      Claims are not being billed, or

2.      Claims are not being billed correctly.

Let me add number 3, health insurance carriers make errors and lots of them. Some of those errors include:

  • Claims paid out of network in error.
  • Lost claims.
  • Supporting data that was submitted with the claim, but somehow is missing
  • Overlooked authorization numbers, referring provider information, etc.
  • Incorrect claim payments and denials.

Yes, a clean claim is critical, but it is only half of the process. Errors occur on both sides. Taking the extra steps to make sure your claim meets the clean claim standard is critical. But errors do occur which is why you also have to keep your eye on A/R and if a claim is not paid, call the health carrier for status.


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