Clean claim

A clean claim is one the payer can adjudicate without stopping. Every field the payer requires is present and valid: the patient’s current member ID and date of birth, the subscriber relationship, the rendering and billing provider NPIs and taxonomy, the correct place of service, procedure codes with the modifiers the payer expects, diagnosis codes that support them and point to the right lines, dates of service inside the authorization and eligibility window, and any attachment or claim note the payer calls for. The claim is also filed inside the payer’s timely filing limit and sent to the right payer in the right order under coordination of benefits.

Clean claims are the whole point of the front end. State prompt-pay laws and many payer contracts start the payment clock only when a clean claim is received, so a claim pended for missing information is not late in the payer’s eyes; it has not started. Each clean claim is money that arrives on the first cycle with nobody touching it twice, which is why clean claim rate and first-pass resolution rate are tracked side by side.

The mistake is assuming clean means accepted. A clearinghouse acceptance only says the file was formatted correctly. A payer can accept a claim into its system and still deny it for a missing authorization or coverage that ended last month. Scrubbers catch format and code-pair errors; verifying eligibility and authorization before the visit catches the rest.