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
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.
What 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.
How does CMS define a clean claim? ›
The term clean claim means 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; and a claim that ...
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 a good clean claim rate? ›
Industry best practice for clean claim rate is 90% or above, which can be a difficult mark to hit. However, there are many ways to increase your clean claim rate and ensure that you're receiving timely and accurate payments.
What is the difference between clean and unclean claims? ›
Clean Claims are claims that have all information in them and nothing is missing. If any mandatory or conditional information is missing, the claim will be considered unclean. Examples of unclean claims include invalid member ID, provider data discrepancy NPI and atax ID does not match.
How long does it take Medicare to pay a clean claim? ›
Your Medicare Part A and B claims are submitted directly to Medicare by your providers (doctors, hospitals, labs, suppliers, etc.). Medicare takes approximately 30 days to process each claim.
What are the risks to the billing process if claims are not clean? ›
Coding errors would lead to claim denials and hence, directly affect the process of revenue cycle management. Over time, the denied claims would stack up till they are corrected and resubmitted. This delay in submission of clean claims would cause financial instability for the medical practice.
What is a clean claim quizlet? ›
clean claim. A claim (paper or electronic) was submitted within the program or policy time limit and contains all necessary information so that it can be processed and paid promptly. ( pg. 217)
What are the requirements for a clean claim? ›
In order to constitute a Clean Claim, the claim must necessarily: a) comply with all standard coding guidelines; b) contain no missing information; and c) be free of any potential defect or impropriety due to unbundling, incorrect or obsolete coding, or medical necessity.
(1) patient's name is required; (2) patient's address is required; (3) patient's date of birth is required; (4) patient's sex is required; (5) patient's relationship to subscriber is required; (6) subscriber's name is required; (7) subscriber's address is required, but the provider may enter "Same" if the subscriber's ...
What is an other than 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 considered a clean claim in Quizlet? ›
clean claim. A claim (paper or electronic) was submitted within the program or policy time limit and contains all necessary information so that it can be processed and paid promptly. ( pg. 217)
Which of the following describes a clean claim? ›
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 ...
What counts as a good claim? ›
—Remember that not all claims are created equal, and though a claim may be arguable, the best claims are focused, specific, complex, and relevant. In arguing a claim, you should always consider potential counterclaims and counterarguments.
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.
