What Is A Clean Claim In Medical Billing?

November 1, 2022

What Is A Clean Claim In Medical Billing?

Medical billing is a complex field that requires a thorough understanding of the rules and regulations.

If you want to get paid for your services, you should always follow the guidelines.

Medical billing is the process of collecting payments from insurance companies or other third parties for healthcare services provided to patients.

The process involves several steps, such as submitting claims, coding diagnoses, and billing procedures.

Keeping on top of the different types of claims is important. Yet, it can also be incredibly confusing.

One of the main varieties is a clean claim. With our help, you can find out exactly what this means.

What Is A Clean Claim?

A clean claim is one where all the details have been accurately provided. There are no mistakes, impropriety, or omissions.

As a result, this claim can be submitted and does not require any further information or investigation.

Ideally, all claims should be clean in medical billing, as they are virtually hassle-free.

For a claim to be valid, it must contain these details:

  • The insurance of the patient is valid. This includes both private and public insurance providers.
  • The diagnosis code. This code is correct and legitimate.
  • Proof that this treatment is covered by a patient’s insurance provider.
  • All of the information is within the correct field or box.
  • The health care provider has included all of the required information about the patient, as listed in their medical records. For example, their date of birth is accurate.
  • The date of service. It’s best to use the exact date of service instead of a range.
  • The location of service.
  • The type of procedure performed and proof of its necessity.

Because of the presence of this information, a clean claim will be accepted immediately, leading to timely payment.

What Is A Dirty Claim?

As you may have guessed from the name, a dirty claim is the exact opposite of a clean one.

It contains errors, inaccuracies, or omissions. This type of claim will need additional work before it can be processed.

In fact, a dirty claim can cause problems with payment processing.

These dirty claims often have incomplete documentation and, therefore, cannot be considered proper claims.

Did you know that the majority of claims that are submitted are inaccurate? More than half of them are incorrect.

This means that many claims are being rejected because of an error.

Unfortunately, these errors are usually due to human error.

This is why it is vital to thoroughly check your insurance claim.

Dirty Vs Clean Claim: What Are The Differences?

There are two main differences between a clean and a dirty claim.

First, a dirty claim usually needs more time to process than a clean one.

This is because it does not contain the correct information.

This means that the right information must be obtained, thus slowing down the claiming process.

Second, a dirty claim requires more effort to complete. Because of its inaccurate nature, it takes longer to submit.

A dirty claim could take up to three times longer than a clean one.

It will require a lot more work, thus causing annoyance for the patient, health care provider, and the insurance agency.

If a claim is clean, it will be carried out.

However, if it is dirty, the health plan will warn the health care provider of inaccuracy 30 days after receipt, though it can increase to 45 days.

Why Are Clean Claims Important?

Why Are Clean Claims Important?

Clean claims are vital to your business.

They ensure that everything is done correctly and that there are no issues when submitting them.

If you have more dirty than clean claims, you will receive lots of late payments from government and private insurance policies.

You can even face penalties if you don’t pay on time.

A hospital or health care provider may develop a negative reputation if they have a poor clean claim rate.

This leads to fewer patients visiting their facility, making these patients afraid that their claims will be mishandled.

How Can I Ensure That My Claim Is Clean?

If you want your claim to be clean, then there are some things you can do.

You should start by ensuring that you provide the necessary information.

Though this may sound obvious, it is always worth double-checking the accuracy of information.

It is super easy to make mistakes.

In fact, most claims are deemed dirty because the information has been inaccurately entered.

Next, if you are unsure whether something is missing, you should check the fields on the form.

If you find an error, then it is important to report it.

The sooner you report it, the better! By doing so, you will help reduce dirty claims.

You must also ensure that you and other members of staff are obeying coding guidelines.

Coding guidelines are rules that dictate how certain codes are assigned. They are used to standardize billing procedures.

When they are followed correctly, they lead to cleaner claims.

These codes are specific to the carrier, so be sure to stay on top of them. Finally, you should keep track of your claims.

Make sure that you know what is going on with each claim. This way, you can spot any issues early on.

As soon as you notice anything amiss, you should contact your carrier.

Frequently Asked Questions

How Do I Know Whether My Claim Is Dirty Or Clean?

The easiest way to tell whether your claim is clean or dirty is to look at the status.

If the claim is clean, then it is set to “Pending”. On the other hand, if the claim is dirty, then it is set as “Rejected”.

You should be informed of this within 30 days of the claim being received.

Why Should I Check My Claim Before Submission?

It is important to check your claim before submission. This ensures that all details are correct.

If you miss out on some information, then it is likely that the claim will not go through.

Therefore, you need to check every field carefully.

Your claim can also be rejected because of omission, meaning that you have left something out.

Therefore, we strongly suggest checking your claim rigorously before sending it off.

Final Thoughts

Hopefully, this article has cleared up some confusion about what a clean claim is.

It’s an ideal situation, but unfortunately, there are times when things go wrong. When this happens, it’s called a dirty claim.

With this information, you can better process claims in medical billing.

Looking for a qualified medical billing service?

By taking just 1 minute to provide some basic information about your practice, you can get up to 5 pre-screened companies competing for your business.

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About the author 

Fred Hopkins

Fred has been connecting medical practices with qualified medical billing and coding professionals since 2016. Helping doctors, of all kinds, streamline patient operations along the way.

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