{"id":14104,"date":"2021-08-17T14:14:45","date_gmt":"2021-08-17T14:14:45","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=14104"},"modified":"2025-06-29T15:14:42","modified_gmt":"2025-06-29T15:14:42","slug":"guidelines-to-submit-a-clean-claim","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/","title":{"rendered":"Guidelines to Submit a Clean Claim"},"content":{"rendered":"<h2 style=\"text-align: left;\"><strong>Defining Clean Claim\u00a0<\/strong><\/h2>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">A clean claim is a submitted claim without any errors or other issues, including incomplete documentation that causes claim rejections or denials. As per the definition of a clean claim first part is correct to claim information and while the second part is not missing any information. <\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">In this blog, we shared guidelines to submit clean claims which include discussing both components i.e., correct information and not missing any information.<\/span><\/p>\n<h2 style=\"text-align: left;\"><strong>Accurate Claim Information<\/strong><\/h2>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">There are several required fields on CMS-1500 for a clean claim, and the claim will get denied if elements are inaccurate. A clean claim should include the accurate entry of the following information:<\/span><\/p>\n<ul style=\"text-align: left;\">\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Details for health care professional, facility information which includes rendering provider name and NPI, billing address, billing NPI, billing tax id number.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Details about patient or insurance plan subscriber, patient and\/or subscriber insurance details, and demographics.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Date of service and place of service.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">If necessary, substantiates the medical necessity and appropriateness of the service provided.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Accurate use of procedural codes, diagnosis codes, and suitable modifiers if required.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Additional documentation based upon services rendered as reasonably required by the health plan.<\/span><\/li>\n<\/ul>\n<h2 style=\"text-align: left;\"><strong>Additional information<\/strong><\/h2>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">There are some insurance details that are not required while every claim. For example, the patient is a minor and he has insurance coverage from his parents. <\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">In this case, demographics information of patients, as well as insurance subscriber, will be required. So, list of such additional information required to submit a clean claim is discussed below:<\/span><\/p>\n<ul style=\"text-align: left;\">\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">If the patient is not a subscriber, then the following details are required:<\/span>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Other insured\u2019s or enrollee\u2019s name (CMS-1500, field 9), is applicable if a patient is covered by more than one health benefit plan. If the essential data element specified in <a href=\"https:\/\/www.cms.gov\/Medicare\/Billing\/ElectronicBillingEDITrans\/HealthCareClaims\">CMS<\/a>-1500, field 11d, \u201cdisclosure of any other health benefit plans,\u201d is answered yes, this is applicable.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">policy\/group number (CMS-1500, field 9a)<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Other insured or enrollee date of birth (CMS-1500, field 9b)<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Other insured or enrollee plan name (employer, school, etc.) (CMS-1500, field 9c)<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Other insured or enrollee HMO or insurer name. If the essential data element specified in CMS-1500, field 11d<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">Subscriber\u2019s plan name (employer, school, etc.) (CMS-1500, field 11b)<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Prior authorization number (CMS-1500, field 23), is applicable when prior authorization is required<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Whether the assignment was accepted (CMS-1500, field 27), is applicable when the assignment has been accepted<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Amount paid (CMS-1500, field 29), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber, or by a primary plan (Commercial or Medicare). When applicable, a copy of the primary plan\u2019s EOB is required<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Balance due (CMS-1500, field 30), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Ambulance trip report, submitted as an attachment to the claim<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">An anesthesia report is applicable to report time spent on anesthesia services.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">To submit a clean, health care providers must bill the insurance companies within one year after the date of service or date of discharge, then only the claim will be considered a clean claim. If Insurance companies rejected or denied the claim, they will reply within 30 days after claim submission. <\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">You will reply with denial codes i.e., exact reasons why the claim is been rejected. If your claim submission is error-free and insurance accepts it, they will provide reimbursement within 30 days and will provide payment details in terms of EOBs (Explanation of Benefits) or ERAs (Electronic Remittance Advice).\u00a0<\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">Most practices struggle with submitting a clean claim as providers are busy inpatient care and can\u2019t provide more attention to medical billing. <\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">A high number of claim rejections and denials will directly affect your practice revenue. <strong>Medical Billers and Coders<\/strong> can assist you in submitting a maximum number of clean claims with help of <a href=\"https:\/\/www.medicalbillersandcoders.com\/specialty-index.aspx\">specialty-wise billing and coding experts<\/a>. <\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">For all our clients, we managed to have a clean claim percentage of 95%. To know more about our clean claim submission services contact us at\u00a0 <\/span><span style=\"font-weight: 400;\"><a href=\"mailto:info@medicalbillersandcoders.com\">info@medicalbillersandcoders.com<\/a>\/<\/span><span style=\"font-weight: 400;\">\u00a0 <strong><a href=\"tel:888-357-3226\">888-357-3226<\/a><\/strong><\/span><\/p>\n<h2 style=\"text-align: left;\">FAQs:<\/h2>\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1751210019050\"><strong class=\"schema-faq-question\">1. What is a clean claim?<\/strong> <p class=\"schema-faq-answer\">A clean claim is a submitted healthcare claim that contains no errors or missing information, ensuring it meets all the necessary requirements for reimbursement without being rejected or denied.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1751210032860\"><strong class=\"schema-faq-question\">2. What information is essential for a clean claim?<\/strong> <p class=\"schema-faq-answer\">Essential elements include accurate details of the healthcare provider (like NPI and tax ID), patient demographics, date and place of service, medical necessity documentation, prior authorization (if needed), and correct procedural and diagnosis codes.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1751210043415\"><strong class=\"schema-faq-question\">3. What happens if a claim is not clean?<\/strong> <p class=\"schema-faq-answer\">If a claim is not clean, it may be denied or rejected by the insurance company. This can delay reimbursement and impact a practice\u2019s revenue, requiring additional time and resources to rectify the issues.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1751210053078\"><strong class=\"schema-faq-question\">4. How can providers ensure their claims are clean?<\/strong> <p class=\"schema-faq-answer\">Providers can ensure clean claims by thoroughly checking all required fields for accuracy, staying updated on coding requirements, and submitting claims within the specified time frame (generally within one year of service).<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1751210062864\"><strong class=\"schema-faq-question\">5. What should practices do if a claim is denied?<\/strong> <p class=\"schema-faq-answer\">If a claim is denied, practices should review the denial codes provided by the insurer to understand the reasons for rejection, make the necessary corrections, and resubmit the claim promptly to facilitate reimbursement.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>Defining Clean Claim\u00a0 A clean claim is a submitted claim without any errors or other issues, including incomplete documentation that causes claim rejections or denials. As per the definition of a clean claim first part is correct to claim information and while the second part is not missing any information. In this blog, we shared [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":14105,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[17],"tags":[],"class_list":["post-14104","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-claims-denials"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v25.5 (Yoast SEO v25.5) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\r\n<title>Strategies to Submit Clean Claim and Reduce Denials<\/title>\r\n<meta name=\"description\" content=\"MBC discovers practical steps you can take to improve your chances of capturing complete, accurate patients for a clean claim and reduced denials.\" \/>\r\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\r\n<link rel=\"canonical\" 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What is a clean claim?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"A clean claim is a submitted healthcare claim that contains no errors or missing information, ensuring it meets all the necessary requirements for reimbursement without being rejected or denied.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/#faq-question-1751210032860","position":2,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/#faq-question-1751210032860","name":"2. What information is essential for a clean claim?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Essential elements include accurate details of the healthcare provider (like NPI and tax ID), patient demographics, date and place of service, medical necessity documentation, prior authorization (if needed), and correct procedural and diagnosis codes.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/#faq-question-1751210043415","position":3,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/#faq-question-1751210043415","name":"3. What happens if a claim is not clean?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"If a claim is not clean, it may be denied or rejected by the insurance company. This can delay reimbursement and impact a practice\u2019s revenue, requiring additional time and resources to rectify the issues.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/#faq-question-1751210053078","position":4,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/#faq-question-1751210053078","name":"4. How can providers ensure their claims are clean?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Providers can ensure clean claims by thoroughly checking all required fields for accuracy, staying updated on coding requirements, and submitting claims within the specified time frame (generally within one year of service).","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/#faq-question-1751210062864","position":5,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/guidelines-to-submit-a-clean-claim\/#faq-question-1751210062864","name":"5. What should practices do if a claim is denied?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"If a claim is denied, practices should review the denial codes provided by the insurer to understand the reasons for rejection, make the necessary corrections, and resubmit the claim promptly to facilitate reimbursement.","inLanguage":"en-US"},"inLanguage":"en-US"}]}},"_links":{"self":[{"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/posts\/14104","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/comments?post=14104"}],"version-history":[{"count":6,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/posts\/14104\/revisions"}],"predecessor-version":[{"id":25197,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/posts\/14104\/revisions\/25197"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/media\/14105"}],"wp:attachment":[{"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/media?parent=14104"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/categories?post=14104"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/tags?post=14104"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}