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Reimbursement Methodologies – Week 5 Lecture 2
Clean vs. Dirty CMS1500/UB04 Claims
A clean claim is a submitted claim without any errors or other issues, including incomplete documentation that delays timely payment.
There are several required elements for a clean claim, and medical bills are denied if elements are incomplete, illegible, or inaccurate. A clean claim meets all the following requirements:
· Identifies the health professional, health facility, home health care provider or durable medical equipment provider who provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.
· Sufficiently identifies the patient and health plan subscriber.
· Lists the date and place of service.
· Is a claim for covered services for an eligible individual?
· If necessary, substantiates the medical necessity and appropriateness of the service provided.
· If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.
· Identifies the service rendered using a generally accepted system of procedure or service coding.
· Includes additional documentation based upon services rendered as reasonably required by the health plan.
A dirty claim is a claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment.
