What is a Clean Claim in Medical Billing

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 reimbursement details between the mentioned parties.

Since medical billing and collection is associated with the reimbursement 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 circumstance 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.