What is clean claim

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

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