Friday, July 2, 2010

What is clean claim - how long to take paid

A “clean” claim is defined as a one that does not require the payer to investigate or develop on a prepayment basis. Clean claims must be filed in the timely filing period.

Most payers consider clean claims as:

◆ Claims that pass all edits

◆ Claims that do not require external development (i.e., are investigated within the claims, medical review, or payment office even if the investigator does not need to contact the provider, the beneficiary, or other outside source)

◆ Claims not approved for payment by the common working file (CWF) within seven days of the original claim submittal for reasons beyond the carrier’s or provider’s control (e.g., CWF system/communication difficulties) (Medicare only)

◆ Claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides (CWF out-of-service area [OSA] claims) (Medicare only)

◆ Claims subject to medical review but complete medical evidence is attached by the provider

◆ Additional requests for information is developed on a post payment basis

◆ Have all basic information necessary to adjudicate the claim, and all required
supporting documentation is attached

Elements of a Clean Claim

1. Clean claim defined: A clean claim has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements, or revisions to data elements,  attachments and additional elements, of which the provider has knowledge. Claims for inpatient and facility programs and services are to be submitted on the UB-04 and  claims for individual professional procedures and services are to be submitted on the CMS-1500. State guidelines may supersede these requirements. In addition, claims may be submitted electronically through a contracted clearinghouse or on Magellan’s Webbased claims submission application. Magellan does not typically, but may require attachments or other information in addition to these standard forms (as noted below). Magellan may request treatment records for review.

2. Required clean claim elements: The Centers for Medicare and Medicaid Services (CMS) developed claim forms that record the information needed to process and generate
provider reimbursement. The required elements of a clean claim must be complete, legible and accurate.


In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the CMS-1500 claim form. For more information about the CMS-1500 form, visit the National Uniform Claim Committee’s website. Note that Magellan can only accept the current version of the CMS-1500 form.

• Subscriber’s/patient’s plan ID number (field 1a);
• Patient’s name (field 2);
• Patient’s date of birth and gender (field 3);
• Subscriber’s name (field 4);
• Patient’s address (street or P.O. Box, city, zip) (field 5);
• Patient’s relationship to subscriber (field 6);
• Subscriber’s address (street or P.O. Box, City, Zip Code) (field 7);
• Whether patient’s condition is related to employment, auto accident, or other accident (field 10);
• Subscriber’s policy number (field 11);
• Subscriber’s birth date and gender (field 11a);
• HMO or preferred provider carrier name (field 11c);
• Disclosure of any other health benefit plans (field 11d);
• Patient’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 12);
• Subscriber’s or authorized person’s signature or notation that the signature is on file
with the physician or provider (field 13);
• Date of current illness, injury, or pregnancy (field 14);
• First date of previous, same or similar illness (field 15);
• Name of Referring Provider or Other Source (field 17);
• Referring Provider NPI Number (field 17b);
• Diagnosis codes or nature of illness or injury (current ICD-10 codes are required effective 10/1/15) (field 21);
• Date(s) of service (field 24A);
• Place of service codes (field 24B);
• EMG (field 24C);
• Procedure/modifier code (current CPT or HCPCS codes are required) (field 24D);
• Diagnosis code (ICD-10 codes are required effective 10/1/15) by specific service (field 24E);
• Charge for each listed service (field 24F);
• Number of days or units (field 24G);
• Rendering provider NPI (field 24J);
• Physician’s or provider’s federal taxpayer ID number (field 25);
• Total charge (field 28);
• Signature of physician or provider that rendered service, including indication of professional license (e.g., MD, LCSW, etc.) or notation that the signature is on file with the HMO or preferred provider carrier (field 31);
• Name and address of facility where services rendered (if other than home or office) (field 32);
• The service facility Type 1 NPI (if different from main or billing NPI) (field 32a);
• Physician’s or provider’s billing name and address (field 33); and
• Main or billing Type 1 NPI number (field 33a).


"Clean" Claim vs. "Non-Clean" Claim:

A claim for payment of health care services that is submitted via an acceptable claim form or electronic format with all required fields completed with accurate and complete information in accordance with the insurer's requirements, is considered "clean" if the following conditions are met:

I. the services must be eligible, provided by an eligible provider and provided to a person covered by the insurer;

II. the claim has no material defect or impropriety, including, but not limited to any lack of required substantiating documentation or incorrect coding;

III. there is no dispute regarding the amount claimed;

IV. the payer has no reason to believe that the claim was submitted fraudulently or there is no material misrepresentation;

V. the claim does not require special treatment or review that would prevent the timely payment of the claim;

VI. the claim does not require coordination of benefits, subrogation, or other third party liability;

VII. services must be incurred during a time where the premium is not delinquent (this condition does not apply to BlueCHiP for Medicare members).

If additional documentation (e.g., medical records) involves a source outside Blue Cross & Blue Shield of Rhode Island (BCBSRI), the claim is not considered clean.

Note: Claims Management uses these criteria to insure that all claims, from both contracted and noncontracted providers, are paid within expected timeframes as outlined by contracts and regulatory agencies.

Clean Claim Summary

A claim that can be processed without obtaining additional information from the provider of the service or its designated representative. It includes a claim with errors originating in a state’s claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.

Prompt Payment

 The Plan shall ensure that clean claims are paid within 30 days of the date of receipt by the Plan. The Plan and the provider may, however, agree to an alternative payment schedule, provided the alternative payment schedule is reviewed and approved by the state of Hawai’i Department of Health Services (DHS). The Plan shall pay interest (according to the interest rate provided by the DHS) for all clean claims that are not paid within these required time frames

Definition of a Clean Claim

In order to be eligible for Prompt Pay penalties, providers must submit a clean claim. A clean claim includes all the data elements specified by the TDI in prompt pay rules or applicable electronic standards. Each specified data element must be legible, accurate, and complete.

For non-electronic submissions by institutional providers, a claim should be submitted using the Centers for Medicare and Medicaid Services (CMS) Form UB-04.1 The UB-04 claim form must include all the required data elements set forth in TDI rules,2 including, if applicable, the amount paid by the primary plan.3

For non- electronic submissions by professional providers, a claim shall be submitted on a CMS Form 1500(02/12) claim form.

Electronic claims by professional or institutional providers must be submitted using the ASC X12N 837 format in order to be considered a clean claim. Providers must submit the claim in compliance with the Federal Health Insurance Portability and Accountability Act (HIPAA) requirements related to electronic health care claims, including applicable implementation guidelines, companion guides, and trading partner agreements.4

A claim that does not comply with the applicable standard is a deficient claim and will not be penalty eligible.5 When Blue Essentials, Blue Advantage HMO and Blue Premier are unable to process a deficient claim, it will notify the provider of the deficiency and request the correct data element.

At times, deficient claims contain sufficient information for BCBSTX’s adjudication and payment. Rather than requiring the provider to correct the deficiency before payment is issued, BCBSTX considers it in the best interest of providers to pay deficient claims as soon as possible. However, because deficient claims are not clean claims, they are not eligible for penalties even if BCBSTX pays the claim outside of the applicable payment period.6

Throughout this provider manual there will be instances when there are references unique to Blue Essentials, Blue Advantage HMO and Blue Premier. These product specific requirements will be noted with the product name.

When a contracting provider submits a clean claim that meets all the requirements for Texas Prompt Pay Act coverage, the insurer must pay the claim within 30 days if it was submitted in electronic format and within 45 days if it was submitted in non-electronic format.7 If a claim is deficient, the statutory period does not commence unless and until the provider corrects the unclean data element(s). The payment period for clean corrected claims is determined by the format of the corrected submission, without regard to the manner in which the original claim was received.

Blue Essentials, Blue Advantage HMO and Blue Premier may extend the applicable statutory payment by requesting additional information from the treating provider within thirty days of receiving a clean claim.8 Such a request suspends the payment period until the requested response is received.9 Blue Essentials, Blue Advantage HMO and Blue Premier must then pay any eligible charges within the longer of (1) fifteen days, or (2) the number of days remaining in the original payment period at the time the request was sent.10

There are three (3) tiers of penalty calculation under the Texas Prompt Pay Act, depending on when the claim was paid. For claims submitted by institutional providers, half of the amount calculated in each tier is owed to the provider and the other half is owed to the Texas Department of Insurance.11

Tier 1: For payments 1 - 45 days late, the total penalty is equal to 50 percent of the difference between the billed charges and the contracted rate.12

Tier 2: For payments 46 – 90 days late, the total penalty is equal to 100 percent of the difference between the billed charges and the contracted rate.13

Tier 3: For payments more than 90 days late, the total penalty is equal to the Tier 2 amount plus 18% annual interest on that amount, accruing from the date payment was due to the date the claim and penalty are paid in full.14

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