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Medicare Definition of Clean Claim
A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.
The following bullets are some examples of what are considered clean claims:
• Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);
• Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).
• Claims not approved for payment by CWF within 7 days of the FI’s original claim submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF system/communication difficulties);
• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;
• Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carrier’s or FI’s instructions;
• Are developed on a postpayment basis; and,
• Have all basic information necessary to adjudicate the claim, and all required supporting documentation
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.
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)
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