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
(ii) Clean claim defined In this paragraph, the term “clean claim” means a claim that has no defect or impropriety (including any lack of any required substantiating documentation) or particular circ*mstance requiring special treatment that prevents timely payment from being made on the claim under this part.
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.
Which of the following is key to submitting a clean claim? ›
Confirm or update basic information like addresses, phone numbers, employer and insurance plan at every patient encounter. Verify eligibility and authorization before the date of service — these steps are critical for submitting clean claims yet account for about a quarter of all denials.
How long does it take to process a clean claim? ›
Some Providers do not have the same financial reserves or diverse payer mix as others and rely on prompt payment from the Medi-Cal program through their MCPs to sustain services to Members. DHCS expects MCPs to pay clean claims within 30 calendar days of receipt.
What is a good clean claims rate vs denial rate? ›
Healthcare providers and practices should aim for a 90% or higher clean claims ratio. If your denial rate is 5% or less, your organization is within a strong, healthy range to prosper.
What is considered 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 ...
Why are clean claims important? ›
A high clean claims rate is essential for healthcare providers and billing organizations because it can lead to faster reimbursem*nt, reduced administrative costs associated with claim resubmissions and appeals, and improved cash flow.
What common errors can prevent clean claims? ›
Simple Errors
- Incorrect patient information. Sex, name, DOB, insurance ID number, etc.
- Incorrect provider information. Address, name, contact information, etc.
- Incorrect Insurance provider information. ...
- Incorrect codes. ...
- Mismatched medical codes. ...
- Leaving out codes altogether for procedures or diagnoses.
- Duplicate Billing.
A non-clean claim is defined as a submitted claim that requires further investigation or development beyond the information contained in the claim.
What are the risks to the billing process if claims are not clean examples? ›
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.
“A clean claim is one that must be submitted with no inconsistencies or other factors, such as insufficient documentation, that would prevent payment.” A clean claim requires numerous elements, and medical bills are turned down if any of these elements are unaccounted, incomprehensible, or inaccurate.
What is a dirty claim in medical billing? ›
In the same vein, you may hear inaccurate or incomplete claims referred to as "dirty claims". If your medical practice has a 95% “clean claims” rate, then that means that all but 5% of claims get to payers with no mistakes upon the first submittal.
What does DCN stand for in medical billing? ›
Subject: Document Control Number (DCN) Search Feature.
How do you calculate the clean claim rate? ›
Clean claim rate is the proportion of claims that do not require edits before submission. It's calculated by dividing the number of claims passing all edits without manual intervention by the total number of claims accepted into a claims processing tool for billing.
What is the benchmark for clean claims rate? ›
An acceptable clean claim rate is 80%, however, to ensure high quality and accuracy maintaining a clean claim rate benchmark of 90% or higher is ideal. Ensuring a high clean claim rate is essential to timely reimbursem*nt.
Who are the biggest claims clearinghouses? ›
National Directory of Electronic Claim Clearinghouses:
- Availity.
- Emdeon.
- MD-Online/MCC.
- RelayHealth.
- Ingenix.
- HealthSmart.
- NHS Net Healthclaims.
- Datatrans Solutions.
dirty claim. a claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment.
What does clean and unclean mean in the Bible? ›
Things that are called unclean (Hebrew tame) in the Old Testament are the opposite of things that are called clean, pure and holy. Uncleanness separated a person from being able to worship at the temple. The emphasis was not on dirt but on God's definition of what is pure.
What is the difference between clean and unclean surroundings? ›
A Dirty environment is a breeding ground for germs while a Clean environment is one that is void of any form of pollution and its effect.
