Submitting Clean Claim Every Time

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Submitting Clean Claim Every Time
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Submitting Clean Claim Every Time

• Clean Claim Requirements
• Submitting clean claims will ensure timely and
  accurate insurance reimbursements. Clean claims
  will ensure that you are not wasting your staffs
  time on reworking insurance claims. As per
  definition, a clean claim is a submitted claim
  without any errors or other issues, including
  incomplete documentation. A clean claim meets all
  of 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.
• Common Claim Rejection Reasons
• Incomplete or wrong information in any applicable
  field of CMS-1500/UB-04 form will lead to claim
  rejection. Some of the common claim rejection
  reasons are listed below

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Submitting Clean Claim Every Time

• Adding or missing proper diagnostics and
  procedure codes. Sometimes having incomplete and
  invalid codes or codes that do not match the
  treatment rendered by the providers. Sometimes
  providers use non-payable diagnosis codes.
• Not submitting claims on time. Most insurance
  carriers allow 60-90 days from the time of
  service to file a claim. When claims are filed
  after a long gap from the date of service, they
  get rejected. This may happen due to the
  unavailability of support/billing staff in any
  practice.
• Ignorant of billing guidelines. For example,
  there is a policy of one service per day for
  behavioral health. This means that even if a
  patient has ten sessions of therapy, the practice
  will not be paid for the second session if two
  are done on the same day.
• Fail to acquire a referral from a provider. For
  some insurance plans, it is essential to get a
  referral from the patients primary care provider
  (PCP) before the service is rendered. The
  referred provider should not provide the service
  before the referral authorization is confirmed by
  the insurance company, or else the claim will be
  denied.
• The practice loses track of sessions. The
  authorization is usually granted for a limited
  number of services/appointments. When you lose
  track of how many sessions are provided or how
  many appointments were approved, then you might
  not get paid for those sessions.
• The prior authorization timed out. The time frame
  for authorizations is as short as 30 days. So, in
  addition to authorizations being for a specific
  number of sessions, they are also time specified.
  Sometimes practices fail to get prior
  authorization altogether.
• Changes in an insurance plan. If a patient
  changes his or her insurance plan, then the
  patient must render a new plan and get new
  pre-authorization. Failing to do so will lead to
  claim rejection.

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Submitting Clean Claim Every Time

• Submitting Clean Claim
• Most practices focus on denial management after
  claims have been processed. The best practice is
  to set up practices and ensure to submit accurate
  claim information every time. Some ways to
  identify problem areas and reduce the costs of
  rejected claims are
• Review clearinghouse reports and validation
  reports before sending the claims. You might find
  claim rejection patterns, which might be payer
  wise, patient wise, or insurance carrier wise.
• Most billing software offers scrubbing tools that
  highlight errors prior to submitting the claims.
  You can review these scrubbing errors, correct
  them, and ensure clean claim submission. You can
  note down the most frequent errors and train your
  team to avoid them while claim submission.
• Identify top rejections by dollar amount and
  volume. Also look for patterns in rejections such
  as ICD codes, CPT codes, or modifiers.
• All the coding errors are supposed to be checked
  beforehand, as the clearinghouse does not always
  catch hold of coding errors. Therefore, make sure
  the medical billing software is compliant with
  current regulations so that there is no room for
  errors.
• Always have updated patient information. This is
  done by making sure that each time a patient
  visits, he/she fills the form with the right type
  of treatment information.
• It should also be kept in mind that insurance
  carriers require timely filing and can deny
  claims based on time limits, so it is extremely
  important to process claims reliably and quickly.

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Submitting Clean Claim Every Time

• Create practice-wide awareness showing how it
  affects the whole organization financially.
• Also, make sure the practice management system
  works effectively when it comes to coding audits,
  checking on eligibility, and demographic edits.
• Submitting a clean claim every time requires a
  set of planned activities, requiring billing and
  coding expertise, and consuming a lot of time. As
  a practice owner, you may not have that amount of
  time or experienced billing staff who understands
  complete revenue cycle management. Medisys Data
  Solutions can assist you in complete revenue
  cycle management for your practice. Our billing
  services include medical specialty-wise coding,
  eligibility verification, charge entry, payment
  posting, denial management, clean claim
  submission, AR management, provider
  credentialing, and enrollment. To know more about
  our complete billing and coding services,
• contact us at info_at_medisysdata.com/ 302-261-9187

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