Clean Claims: What They Are and How to Submit

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Clean Claims: What They Are and How to Submit

Tuesday, May 31, 2016

Clean claims fuel your practice's revenue and cash flow, but what do they mean exactly? We explain what they are, who authorizes them and how to submit clean claims so your practice can send them out the first time, every time.

Clean claim definition

A clean claim is a submitted claim without any errors or other issues, including incomplete documentation that delays timely payment.

There are several required elements for a clean claim, and medical bills are denied if elements are incomplete, illegible or inaccurate. 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.
  • Sufficiently identifies the patient and health plan subscriber.
  • Lists the date and place of service.
  • Is a claim for covered services for an eligible individual.
  • If necessary, substantiates the medical necessity and appropriateness of the service provided.
  • If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.
  • Identifies the service rendered using a generally accepted system of procedure or service coding.
  • Includes additional documentation based upon services rendered as reasonably required by the health plan.

Clean claim authorization

The Department of Insurance and Financial Services is responsible for the regulation of insurance transactions in Michigan. DIFS generally only accepts complaints from parties involved in the contract, including the insured, policyholder or certificate holder. Because a health care provider is usually not a party to the health care contract, DIFS does not accept complaints from providers. However, there are some exceptions to the policy.

DIFS will pursue appropriate complaints from providers, acting as the authorized representative of a patient covered by a Michigan licensed health carrier, as long as written authorization from the patient or their legal representative is included with the complaint.

Clean claim submission

Health care providers (a health professional, health facility, home health care provider or durable medical equipment provider) must bill a health plan within one year after the date of service or date of discharge in order for the claim to be considered clean.

A Clean Claim Report must be filed with the Office of Financial and Insurance Regulation for each claim that a health plan has not timely paid. View a Clean Claim Report here.

Clean claim payment

A clean claim must be paid and corrected of 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 notifies a health care provider that the claim contains issues. 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 does determine that services listed on a claim are payable, the health plan shall pay for those services and shall not deny the entire claim because other services listed on the claim are defective.

A health professional, health facility, home health care provider or durable medical equipment provider cannot resubmit the same claim to the health plan unless the 45-day time frame has passed.

Michigan State Medical Society members can view legal alerts on clean claims and timely payment laws here.

For more information about clean claims, visit our resources page here. To find clean claim language in statute, click here and here.