What is a clean claim in medical billing

What is a Clean Claim in Medical Billing?

A clean claim is one that needs to be submitted without any discrepancies or other issues, such as inadequate evidence, that would impede payment. An increased Clean Claim Rate indicates that the information collected and analyzed within the electronic health record (EHR) is of high quality. It implies that claim processes are incredibly accurate. Irrespective of how a high CCR is achieved, whether through improved initial accuracy or custom claim intake routines, the result is a shorter time to pay with less manual labor and lower operational costs. To get a complete guide on: what is a clean claim in medical billing and its importance, scroll down the blog.

What Does “Clean Claim” Imply in Medical Billing?

Clean claims significantly raise revenue and cash flow in your practice, but what do they imply? We define what is a clean claim in medical billing, and how to submit clean claims so that your practice can submit them correctly the first time.

“A clean claim is one that must be submitted with no inconsistencies or other factors, such as insufficient documentation, that would prevent payment.”

A clean claim requires numerous elements, and medical bills are turned down if any of these elements are unaccounted, incomprehensible, or inaccurate. A clean claim meets all of the following criteria: Acknowledges the medical provider, health facility, residential healthcare provider, or provider of durable medical claims billing service who provided the service in considerable detail to verify affiliation status, if necessary, and includes any recognizing counts.

  • Identifies the patient and health plan payment fee sufficiently.
  •  The date and location of the service that is stated
  • Claim for insurance coverage made on behalf of an eligible individual.
  • If necessary, provides evidence to support the medical necessity and appropriateness of the services delivered.
  • If prior authorization is needed for certain patient services, include enough information to prove that prior authorization has been obtained.
  • Identifies the services provided using a commonly accepted procedure or service coding system; and

What Effect Do Clean Claims Have on Healthcare Practices?

After getting an insight into what is a clean claim in medical billing? Let’s take a tour of the effect of the clean claim. Your clean claims rate has a direct influence on the total revenue of your medical practice. Troublesome billing and coding practices on your team can lead to delayed or denied claims, which can be devastating for healthcare practices. Many rejected claims are refiled multiple times with errors that are frequently not tried to address or rectify. Incorrectly submitted claims can also result in legal issues. You may be identified for potential fraud and misconduct if your medical practice offers excessively poorly completed claims.

Why are Clean Claims Important?

Along with what is a clean claim in medical billing, it’s significant to explore its importance. Inability to report clean claims; claims that flow through the clearinghouse, arrive at the payer, and have a negative impact on the practice’s revenue and cash flow. Medical procedures consistently submit a substantial portion of their claims in a way that results in denials when they arrive at the clearinghouse or insurer. A medical practice’s claim submission can confront a relatively close percentage by integrating coding principles and claim scrubbing functionality. Claim scrubbing reduces claim errors, claim rejections, and denials such as the ones mentioned below, which are frequently shown on an explanation of benefits (EOB) or electronic remittance (ERA) advice:

  • The CPT code is not accurate for the service date.
  • A Patient treatment code is missing. 
  • The specific  treatment code is erroneous.
  • Member is ineligible to serve on the date.
  • Inaccurate member ID

When revised CPT and ICD codes are announced, verify all billable codes to decrease inconsistencies. Moreover, acknowledging changes to the principles and payer regulations can ensure proper coding and reduce patient payments delays.

The time it necessitates to receive reimbursement from the payer can be reduced if the claim departs your practise management system “clean” on the initial submission.

Easy Steps to Ensure Clean Claim

What is a clean claim in medical billing

Verify all billable codes to decrease inconsistencies when revised CPT and ICD codes are announced. Moreover, acknowledging changes to the principles and payer regulations can ensure proper coding and reduce patient payments delays. The time it necessitates to receive reimbursement from the payer can be reduced if the claim enters your practice management system “clean” on the initial submission.

Ensure Patient Information is Correct

Inconsistencies in patient data are an exasperatingly simple reason a medical claim is rejected. You can avoid these mistakes by keeping patient information current in the electronic health record (EHR) and analyzing it each time a follow-up appointment.

Follow Updated Medical Coding Regulations

Medical coding regulations are constantly changing. Even if you employ office staff that performs medical billing, keeping up with the latest changes can be difficult. If nothing else, outsource medical billing makes more sense. Medical claims billing solutions focus entirely on medical billing. As a result, they are almost always up to date on any new code variables associated.

Perform Quality Checks

Quality assurance is a significant step before submitting claims. Several items must be reevaluated during the check, including patient demographics, medical codes and enhancers used, and other details. Some medical claims billing software employs a claims scrubber, which checks every claim for inconsistencies before submitting it.

How to Increase your Clean Claim Ratio?

It’s not enough to know about what is a clean claim in medical billing. It’s also an indication of how to increase the clean claim ratio. As a medical professional, you’re likely familiar with Medical revenue cycle management. It is critical for your practice’s operating margins to ensure that it receives timely payment from insurance payers. The clean claim rate is an important revenue cycle metric that monitors how well you manage your cash flow.

A clean claim is an insurance policy that results in an increase and reimbursement within the first attempt. This implies no discrepancies, refusals, or the need for metadata to be manually entered. A high clean claim rate tells insurance companies that the data you’re capturing is of top quality. It also demonstrates that healthcare providers pay attention to claim accuracy from beginning to end. When you submit a clean claim, the insurer spends less time processing it. As a result, you would also receive payment more quickly.

The accepted practice for a clean claim rate is 95% or higher, which can be challenging. However, there are numerous ways to improve your clean claim rate and ensure that you receive precise and timely payments.

Claim Scrubbing

A reputable Revenue Cycle Management service provider is dedicated to improving your clean claim rate. That really can be done in order to avoid submitting a claim if it cannot be approved. Claims scrubbing is a checkpoint system that your efficient medical billing partner must provide. Staying current on payer regulatory requirements is critical to avoid claim rejection. RCM service providers remain current on all medical coding, ensuring that your claims are correctly coded before submission. Denials are prevalent when a claim is coded inaccurately or is required to submit too late. Claims scrubbing ensures that coding errors are indicated and corrected as soon as possible before submission. Providers can save money by working with a medical coding professional.

Medical Billing Partner

The clean claim rate is a crucial measure of the efficiency of your revenue cycle management. Collaborating with an RCM services vendor to put more emphasis exclusively on increasing the clean claim rate is a excellent way to start. That can enable your personnel to concentrate on more patient-physician tasks while ensuring that claims are being monitored for inconsistencies. A medical billing partner can also take the necessary steps to keep your clean claims rate above 95%.

Education and Training

All personnel involved in any aspect of the healthcare revenue cycle Management can be educated on the importance of an increased clean claim, the prevalent inconsistencies that occur, and strategies for improving it. Your medical billing services partner can provide training before during and after deployment.

Your partners work hard to boost your clean claim rate. The properly informed staff is aware of appropriate billing practices and knows how to use medical billing software.

Software for Medical Billing

Numerous medical billing software providers, like Medifusion, can assist with claim submission. Another significant factor in maintaining a high clean claim rate is using powerful healthcare billing software in your practice. Many services offer billing analytics tools to assist with prior authorizations and identify code errors when they are posted. This helps the provider establish a solid revenue cycle that adheres to regulatory requirements. Clearinghouse changes or updates and claim scrub features are built into high-quality EHR software, making it possible to spot and take corrective measures before they are forwarded to the payer for reimbursement.

Improve your Clean Claims Ratios with Bellmedex 

From the details mentioned above, you can get information about what is a clean claim in medical billing and its importance. Medical billing companies make it their business to keep you informed on new healthcare regulations and proposals and ensure your revenue cycle is as streamlined as possible. If your practice is overstretched with claims that need to be submitted or reconfigured, it may be time to consider partnering with a medical billing firm to manage it properly.

With the help of a medical billing company like Bellmedex, you can see an immediate increase in revenue, have more time to focus on patients, develop strategic advances for your healthcare practice, and gain a new perspective into your business’s performance.

We have expertise in your industry and can guide you through the intricacies of the medical coding and billing methodology so you can concentrate on what’s most important: providing excellent care to your patients. We offer a wide range of billing services including, dental billing services, chiropractic billing services, therapist billing services, and much more, including:

  • Insurance verification online
  • EHR documentation
  • Processing of insurance claims
  • Insurance certification

If you want to learn more about dental practice management software, read the blog:

“Best Dental Practice Management Software


We are going to wrap up: “What is a clean claim in medical billing” The medical billing claim submission process can be challenging. When properly managed, the claim processing flow is simple and encouraging. Clean claims result in fewer claim denials, resulting in shorter accounts receivable times. Clean claims start driving total revenue and ensure healthy cash flow for healthcare providers. Each time a claim is denied, it lends bulk to your accounts and reduces the revenue generated by your medical practice. Denials are costly in terms of both valuable time and money.

Getting it right is critical to your revenue stream, keeping your tradition, and trying to move forward quickly and effectively.

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