Why clean claims are best ?

Proportion of “Clean” Claims

The vast majority of claims received, whether electronically or on paper, are “clean” and do not present problems with missing information or format errors. Claims received electronically have some advantage over paper claims across all provider categories surveyed. On average about 94 percent of claims received electronically are clean versus 86 percent of paper claims. Physicians
do slightly better on their percentage of clean claims than do hospitals (97 percent versus 94 percent for electronic claims and 89 percent versus 87 percent for paper), and both do better than other health care providers.

Automatic Adjudication of Claims

Electronically submitted claims have a large advantage over paper in the automatic adjudication of claims (claims processed without human involvement once they are entered into the processing system). There is almost a two-to-one margin in the percentage of electronic versus paper claims that are so adjudicated (49 percent versus 27 percent respectively). Automatic adjudication of claims allows for quicker processing times and less costly processing than manual intervention resulting in savings to the health plan, providers, and ultimately consumers.

Definition of a Clean Claim

In order to be eligible for Prompt Pay penalties, providers must submit a clean claim. A clean claim includes all the data elements specified by the TDI in prompt pay rules or applicable electronic standards. Each specified data element must be legible, accurate, and complete.

For non-electronic submissions by institutional providers, a claim should be submitted using the Centers for Medicare and Medicaid Services (CMS) Form UB-04.1 The UB-04 claim form must include all the required data elements set forth in TDI rules,2  including, if applicable, the amount paid by the primary plan.3

For non- electronic submissions by professional providers, a claim shall be submitted on a CMS Form 1500(02/12) claim form.

Electronic claims by professional or institutional providers must be submitted using the ASC X12N 837 format in order to be considered a clean claim. Providers must submit the claim in compliance with the Federal Health Insurance Portability and Accountability Act (HIPAA) requirements related to electronic health care claims, including applicable implementation guidelines, companion guides, and trading partner agreements.4

A claim that does not comply with the applicable standard is a deficient claim and will not be penalty eligible.5   When Blue Essentials, Blue Advantage HMO and Blue Premier are unable to process a deficient claim, it will notify the provider of the deficiency and request the correct data element.

At times, deficient claims contain sufficient information for BCBSTX’s adjudication and payment. Rather than requiring the provider to correct the deficiency before payment is issued, BCBSTX considers it in the best interest of providers to pay deficient claims as soon as possible. However, because deficient claims are not clean claims, they are not eligible for penalties even if BCBSTX pays the claim outside of the applicable payment period.