What is a clean claim?
A clean claim is a successfully processed and reimbursed insurance claim. A clean claim rate has no errors, rejections, or need for manual intervention or additional data.
Having a high rate of clean claims demonstrates an organization’s ability to capture and enter quality data the first time. Submitting a clean claim leads to quicker reimbursement and account resolution.
Criteria for a Clean Claim:
- A clean claim is submitted by a licensed healthcare provider.
- The coverage of a clean claim was in effect on the date that the organization provided the healthcare service. Also, the services covered must be under the patient’s health insurance.
- To eliminate questions on medical necessity, procedure codes must support the diagnosis codes.
- All the codes used on the claim must be current.
- All information must be correct and placed on the appropriate fields of the claim form.
- Accurate identification of payer, including the payer ID and the mailing address.
- The claim must submit it within a specified time.
- Any other required supporting documents are provided.
Why do Insurance Claims get Denied?
Insurance companies have strict regulations. Furthermore, their standard operating procedures are ever-changing. Most of the time, claims get denied because of improper patient care, but there can be other mistakes like:
- Late submission of documents
- Incomplete or insufficient supporting documents
- Patient not eligible for services
- Overlapping coverage dates
- Missing pre-authorization/ pre-certification
Proven and Tested Ways to Increase Clean Claim Rate
There are many possible ways to hit that industry’s best clean claim rate of 90%. To start, having thorough claims procedures is a must.
Healthcare providers must keep up with the ever-changing rules that affect claim submissions. Furthermore, they must also review the claim denials and underpayments to unveil additional reimbursement delays. Also, they need to be sure that both the clinical and the financial staff communicate. Effective communication will ensure that everyone in the organization understands the part they play in revenue cycle management.
From intelyHealth’s years of experience in the healthcare IT space, we have learned many ways to increase healthcare organizations’ clean claim rates. We have listed the top 3 that we have seen and proven to be successful.