A “clean” claim is defined as a one that does not require the payer to investigate or develop on a prepayment basis. Clean claims must be filed in the timely filing period.
◆ Claims that do not require external development (i.e., are investigated within the claims, medical review, or payment office even if the investigator does not need to contact the provider, the beneficiary, or other outside source)
◆ Claims not approved for payment by the common working file (CWF) within seven days of the original claim submittal for reasons beyond the carrier’s or provider’s control (e.g., CWF system/communication difficulties) (Medicare only)
◆ Claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides (CWF out-of-service area [OSA] claims) (Medicare only)
◆ Claims subject to medical review but complete medical evidence is attached by the provider
◆ Have all basic information necessary to adjudicate the claim, and all required
supporting documentation is attached
Elements of a Clean Claim
1. Clean claim defined: A clean claim has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements, or revisions to data elements, attachments and additional elements, of which the provider has knowledge. Claims for inpatient and facility programs and services are to be submitted on the UB-04 and claims for individual professional procedures and services are to be submitted on the CMS-1500. State guidelines may supersede these requirements. In addition, claims may be submitted electronically through a contracted clearinghouse or on Magellan’s Webbased claims submission application. Magellan does not typically, but may require attachments or other information in addition to these standard forms (as noted below). Magellan may request treatment records for review.
2. Required clean claim elements: The Centers for Medicare and Medicaid Services (CMS) developed claim forms that record the information needed to process and generate provider reimbursement. The required elements of a clean claim must be complete, legible and accurate.
CMS-1500
In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the CMS-1500 claim form. For more information about the CMS-1500 form, visit the National Uniform Claim Committee’s website. Note that Magellan can only accept the current version of the CMS-1500 form.
• Subscriber’s/patient’s plan ID number (field 1a);
• Patient’s name (field 2);
• Patient’s date of birth and gender (field 3);
• Subscriber’s name (field 4);
• Patient’s address (street or P.O. Box, city, zip) (field 5);
• Patient’s relationship to subscriber (field 6);
• Subscriber’s address (street or P.O. Box, City, Zip Code) (field 7);
• Whether patient’s condition is related to employment, auto accident, or other accident (field 10);
• Subscriber’s policy number (field 11);
• Subscriber’s birth date and gender (field 11a);
• HMO or preferred provider carrier name (field 11c);
• Disclosure of any other health benefit plans (field 11d);
• Patient’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 12);
• Subscriber’s or authorized person’s signature or notation that the signature is on file
with the physician or provider (field 13);
• Date of current illness, injury, or pregnancy (field 14);
• First date of previous, same or similar illness (field 15);
• Name of Referring Provider or Other Source (field 17);
• Referring Provider NPI Number (field 17b);
• Diagnosis codes or nature of illness or injury (current ICD-10 codes are required effective 10/1/15) (field 21);
• Date(s) of service (field 24A);
• Place of service codes (field 24B);
• EMG (field 24C);
• Procedure/modifier code (current CPT or HCPCS codes are required) (field 24D);
• Diagnosis code (ICD-10 codes are required effective 10/1/15) by specific service (field 24E);
• Charge for each listed service (field 24F);
• Number of days or units (field 24G);
• Rendering provider NPI (field 24J);
• Physician’s or provider’s federal taxpayer ID number (field 25);
• Total charge (field 28);
• Signature of physician or provider that rendered service, including indication of professional license (e.g., MD, LCSW, etc.) or notation that the signature is on file with the HMO or preferred provider carrier (field 31);
• Name and address of facility where services rendered (if other than home or office) (field 32);
• The service facility Type 1 NPI (if different from main or billing NPI) (field 32a);
• Physician’s or provider’s billing name and address (field 33); and
• Main or billing Type 1 NPI number (field 33a).
Definitions
"Clean" Claim vs. "Non-Clean" Claim:
A claim for payment of health care services that is submitted via an acceptable claim form or electronic format with all required fields completed with accurate and complete information in accordance with the insurer's requirements, is considered "clean" if the following conditions are met:
I. the services must be eligible, provided by an eligible provider and provided to a person covered by the insurer;
II. the claim has no material defect or impropriety, including, but not limited to any lack of required substantiating documentation or incorrect coding;
III. there is no dispute regarding the amount claimed;
IV. the payer has no reason to believe that the claim was submitted fraudulently or there is no material misrepresentation;
V. the claim does not require special treatment or review that would prevent the timely payment of the claim;
VI. the claim does not require coordination of benefits, subrogation, or other third party liability;
VII. services must be incurred during a time where the premium is not delinquent (this condition does not apply to BlueCHiP for Medicare members).
If additional documentation (e.g., medical records) involves a source outside Blue Cross & Blue Shield of Rhode Island (BCBSRI), the claim is not considered clean.
Note: Claims Management uses these criteria to insure that all claims, from both contracted and noncontracted providers, are paid within expected timeframes as outlined by contracts and regulatory agencies.
Clean Claim Summary
A claim that can be processed without obtaining additional information from the provider of the service or its designated representative. It includes a claim with errors originating in a state’s claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.
Prompt Payment
The Plan shall ensure that clean claims are paid within 30 days of the date of receipt by the Plan. The Plan and the provider may, however, agree to an alternative payment schedule, provided the alternative payment schedule is reviewed and approved by the state of Hawai’i Department of Health Services (DHS). The Plan shall pay interest (according to the interest rate provided by the DHS) for all clean claims that are not paid within these required time frames
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.6
Throughout this provider manual there will be instances when there are references unique to Blue Essentials, Blue Advantage HMO and Blue Premier. These product specific requirements will be noted with the product name.
When a contracting provider submits a clean claim that meets all the requirements for Texas Prompt Pay Act coverage, the insurer must pay the claim within 30 days if it was submitted in electronic format and within 45 days if it was submitted in non-electronic format.7 If a claim is deficient, the statutory period does not commence unless and until the provider corrects the unclean data element(s). The payment period for clean corrected claims is determined by the format of the corrected submission, without regard to the manner in which the original claim was received.
Blue Essentials, Blue Advantage HMO and Blue Premier may extend the applicable statutory payment by requesting additional information from the treating provider within thirty days of receiving a clean claim.8 Such a request suspends the payment period until the requested response is received.9 Blue Essentials, Blue Advantage HMO and Blue Premier must then pay any eligible charges within the longer of (1) fifteen days, or (2) the number of days remaining in the original payment period at the time the request was sent.10
There are three (3) tiers of penalty calculation under the Texas Prompt Pay Act, depending on when the claim was paid. For claims submitted by institutional providers, half of the amount calculated in each tier is owed to the provider and the other half is owed to the Texas Department of Insurance.11
Tier 1: For payments 1 - 45 days late, the total penalty is equal to 50 percent of the difference between the billed charges and the contracted rate.12
Tier 2: For payments 46 – 90 days late, the total penalty is equal to 100 percent of the difference between the billed charges and the contracted rate.13
Tier 3: For payments more than 90 days late, the total penalty is equal to the
Tier 2 amount plus 18% annual interest on that amount, accruing from the date payment was due to the date the claim and penalty are paid in full.14
Submitting Accurate Claims
Health care professionals and suppliers play a vital role in protecting the integrity of the Medicare Program by submitting accurate claims, maintaining current knowledge of Medicare billing policies, and ensuring all documentation required to support the medical need for the service rendered is submitted when requested by the MAC.
In addition to correct claims completion, Medicare payment requires that an item or service:
• Meets a benefit category
• Is not specifically excluded from coverage
• Is reasonable and necessary
In general fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.
ASCA Exceptions: Before submitting a hard copy claim on the Form CMS-1500, health care professionals and suppliers are required to self-assess to determine whether they meet one or more of the ASCA exceptions. For example, health care professionals and suppliers that have fewer than10 Full-Time Equivalent (FTE) employees and bill a MAC are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If a health care professional or supplier meets an exception, there is no need to submit a waiver request.
Waiver Requests: There are other situations when the ASCA electronic billing requirement could be waived for some or all claims, such as if disability of all members of a health care professional’s or supplier’s staff prevents use of a computer for electronic submission of claims. Health care professionals and suppliers must obtain Medicare preapproval to submit paper claims in these situations by submitting a waiver request to their MAC.
Clean claim definition for UB 04
Clean claim defined: A clean claim has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements, or revisions to data elements, attachments and additional elements, of which the provider has knowledge. Claims for inpatient and facility programs and services are to be submitted on the UB-04 and claims for individual professional procedures and services are to be submitted on the CMS-1500. State guidelines may supersede these requirements. In addition, claims may be submitted electronically through a contracted clearinghouse or on Magellan’s webbased claims submission application. Magellan does not typically, but may require attachments or other information in addition to these standard forms (as noted below). Magellan may request treatment records for review.
Required clean claim elements: The Centers for Medicare and Medicaid Services (CMS) developed claim forms that record the information needed to process and generate provider reimbursement. The required elements of a clean claim must be complete, legible and accurate.
UB-04
The UB-04 form captures essential data elements for providers of services in institutional/inpatient/facility settings. The form can be used to bill Medicare fiscal intermediaries, Medicaid state agencies and health plans/insurers. The required elements of a clean claim must be complete, legible and accurate. For more information about the UB-04 form, visit the National Uniform Billing Committee’s website. Contact your claim forms vendor to obtain full-color versions of the UB-04.
In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the UB-04 claim form.
• Provider’s name, address and telephone number (field 1);
• Patient control number (field 3a);
• Type of bill code (field 4);
• Provider’s federal tax ID number (field 5);
• Statement period (beginning and ending date of claim period) (field 6);
• Patient’s name (field 8);
• Patient’s address (field 9);
• Patient’s date of birth (field 10);
• Patient’s gender (field 11);
• Date of admission (field 12), required for inpatient and home health;
• Admission hour (field 13);
• Type of admission (e.g. emergency, urgent, elective, newborn) (field 14), required for inpatient;
• Source of admission code (field 15);
• Patient-status-at-discharge code (field 17);
• Value code and amounts (fields 39-41);
• Revenue code (field 42);
• Revenue/service description (field 43);
• HCPCS/Rates (current CPT or HCPCS codes are required) (field 44);
• Service date (field 45), (required for each date of facility-based non-inpatient services or itemization in a separate attachment is required);
• Units of service (field 46);
• Total charge (field 47);
• HMO or preferred provider carrier name (field 50);
• Main NPI number (field 56);
• Subscriber’s name (field 58);
• Patient’s relationship to subscriber (field 59);
• Insured’s unique ID (field 60);
• Diagnosis qualifier (field 66);
• Principal diagnosis code (ICD-10 codes are required effective 10/1/15) (field 67);
• Admit diagnosis (field 69);
• Provider name and identifiers (field 76-79).
Situational clean claim elements: Unless otherwise agreed by contract, the data elements contained in this paragraph are necessary for claims filed by physicians or providers if circumstances exist which render the data elements applicable to the specific claim being filed. The applicability of any given data element contained in this paragraph is determined by the situation from which the claim arose.
(1) Other insured’s or enrollee’s name (CMS-1500, field 9), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(2) Other insured’s or enrollee’s policy/group number (CMS-1500, field 9a), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in paragraph CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(3) Other insured or enrollee date of birth (CMS-1500, field 9b), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in paragraph CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(4) Other insured or enrollee plan name (employer, school, etc.) (CMS-1500, field 9c), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(5) Other insured or enrollee HMO or insurer name. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.
(6) Subscriber’s plan name (employer, school, etc.) (CMS-1500, field 11b) is applicable if the health benefit plan is a group plan;
(7) Prior authorization number (CMS-1500, field 23), is applicable when prior authorization is required;
(8) Whether assignment was accepted (CMS-1500, field 27), is applicable when assignment has been accepted;
(9) 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’s EOB is required;
(10) 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;
(11) Pay To name, address and ID (UB-04, field 2), required when the Pay To information is different than Billing provider info in field 1;
(12) Medical/ health record number (UB-04, field 3b), not the same as 3a;
(13) Discharge hour (UB-04, field 16), is applicable if the patient was an inpatient, or was admitted for outpatient observation;
(14) Condition codes (UB-04, fields 18-28 are applicable if the CMS UB-04 manual contains a condition code appropriate to the patient’s condition;
(15) Occurrence codes and dates (UB-04, fields 31-34), are applicable if the CMS UB- 04 manual contains an occurrence code appropriate to the patient’s condition;
(16) Occurrence span code, from and through dates (UB-04, field 35-36), is applicable if the CMS UB-04 manual contains an occurrence span code appropriate to the patient’s condition;
(17) Non-covered charges (UB-04, field 48), required when applicable;
(18) Prior payments – payer and patient (UB-04, field 54), is applicable if payments have been made to the physician or provider by the patient or another payer or subscriber, on behalf of the patient or subscriber, or by a primary plan;
(19) Diagnoses codes other than principle diagnosis code (UB-04, fields 67A-Q), is applicable if there are diagnoses other than the principle diagnosis and ICD-10 code is required effective 10/1/15;
(20) Principal procedure code and date (UB-04, field 74), required on inpatient claims when a procedure was performed; Other procedure codes and dates (UB-04, field 74a-e), required on inpatient claims when additional procedures must be reported;
(21) Ambulance trip report, submitted as an attachment to the claim; and
(22) Anesthesia report is applicable to report time spent on anesthesia services.
Additional clean claim elements: In the event information not specified herein is required to make an accurate determination of proof of loss, the provider will be notified in writing within the applicable regulatory or contractual prompt payment standards. The notice will identify the specific claim or portion of a claim that is being reviewed and the information required. The review is completed within the applicable prompt payment standard following receipt of the information requested from the provider.
Medicare payment policy on Clean claims
Under the existing legislated payment floor, electronic media claims
(EMC) may not be paid earlier than the 14th day after the date of receipt (13-day waiting period). Non-electronic claims cannot be paid earlier than the 27th day after the date of receipt (26-day waiting period). The Health Insurance Portability and Accountability Act (HIPAA) requires that claims submitted electronically effective October 16, 2003 be in a format that complies with the appropriate standard adopted for national use. Claims submitted via direct data entry (DDE) where supported by a carrier or intermediary are considered to be HIPAAcompliant electronic claims.
The Administrative Simplification and Compliance Act (ASCA) requires that claims be submitted to Medicare electronically by October 16, 2003, with some exceptions. A contingency plan has been invoked to temporarily accept electronic claims in a non-HIPAA format after October 15, 2003 while submitters complete implementation and testing efforts.
To support the goal in the HHS July 24, 2003, HIPAA contingency planning document that trading partners be encouraged to comply with the HIPAA standards requirements as soon as possible, CMS is modifying application of the payment floor. Only those claims submitted electronically in a HIPAA-compliant claim format will now be considered eligible for payment as early as the 14th day after the date of receipt. All other claims, including those submitted electronically in a pre-HIPAA format under a Medicare contingency plan, will not be paid earlier than the 27th day after the date of receipt.
For CROWD workload reporting purposes, only HIPAA-compliant electronic claims may now be reported in the EMC category. Non-HIPAA compliant EMC must now be included in the total reported in the paper claims category. This payment floor differentiation between HIPAA-compliant and non-HIPAA-compliant electronic claims does not apply to the payment ceiling (30-days for all clean claims), nor to the Contractor Performance Evaluation (CPE) requirement that 95% of clean electronic (HIPAA or non-HIPAA compliant) and paper claims be processed by the statutorily specified timeframes.
The receipt date is the date the carrier or FI receives a claim on which the data are sufficiently complete to qualify as a claim. The receipt date is used to calculate interest payments when due for clean claims, to report statistical data on claims to CMS, such as in workload reports, and to determine if a claim was received timely.
Paper claims received by 5:00 p.m. on a business day, or by closing time if the carrier or FI routinely ends its public business day between 4:00 p.m. and 5:00 p.m., must be considered as received on that date, even if the carrier or FI does not open the envelopes in which the claims are received or does not enter the data into the claims processing system until a later date. Paper claims received after 5:00 p.m. or the carrier or FI’s close of business between 4:00 p.m. and 5:00 p.m. may be considered as received on the next business day.
Paper claims are considered received if delivered to the carrier or FI’s place of business by the U.S. Postal Service, picked up from a P.O. box(es), or otherwise delivered to the carrier or FI’s place of business by its normal close of business time. If the carrier or FI uses a P.O. box for receipt of mailed claims, it must have its mail picked up from its box(es) at least once per business day unless precluded on a particular day by the emergency closing of its office or its postal box site.
As electronic claim tapes and diskettes that may be submitted by providers or their agents to an FI are also subject to manual delivery, rather than direct electronic transmission, the paper claim receipt date establishment rule also applies to establish the date of receipt of claims submitted on such tapes and diskettes.
Electronic claims transmitted directly to a FI, carrier, or to a clearinghouse with which the FI or carrier contracts as its representative for the receipt of its claims, by 5:00 p.m. in the FI’s or carrier’s time zone, or by its closing time if it routinely closes between 4:00 p.m. and 5:00 p.m., must likewise be considered as received on that day even if the FI or carrier does not upload or process the data until a later date. NOTE: The payment floor differentiation in 80.2.1.2 does not apply when establishing date of receipt. Use the same methodology to establish the date of receipt for all electronic claims.
Paper and electronic claims that do not meet the basic legibility, format, or completion requirements are not considered as received for claims processing and may be rejected from the claims processing system. Rejected claims are not considered as received until resubmitted as corrected, complete claims. The carrier or FI may not use the data entry date, the date of passage of front-end edits, the date the document control number is assigned, or any date other than the actual calendar date of receipt as described above to establish the official receipt date of any claim.
Payment ceilings were implemented for clean claims received by the carrier or FI on or after April 1, 1987. “Clean” claims must be paid or denied within the applicable number of days from their receipt date as follows:
Time Period for Claims Received Applicable Number of Calendar Days
01-01-93 through 09-30-93 24 for EMC and 27 for paper claims
10-01-93 and later 30
All claims (i.e., paid claims, partial and complete denials, no payment bills) including PIP and EMC claims are subject to the above requirements.
Interest must be paid on claims that are not paid within the ceiling period.
The count starts on the day after the receipt date and it ends on the date payment is made. For example, for clean claims received October 1, 1993, and later, if this span is 30 days or less, the requirement is met.
RAPs submitted by home health agencies under the HH PPS (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not Medicare claims as defined under the Social Security Act. Since they are not considered claims, they (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not subjected to payment ceiling standards and interest payment.
For purposes of the payment floors and ceilings, for Medicare purposes:
An “electronic claim” is one that is submitted via central processing unit (CPU) to CPU transmission, tape, diskette, direct data entry, direct wire, or personal computer upload or download. Claims submitted via digital FAX/OCR, diskette or touch-tone phone are not counted or paid as EMC. See 80.2.1.2 for differentiation between electronic claims that comply with the requirements of the standard implementation guides adopted for national use under HIPAA and those submitted electronically using pre-HIPAA formats supported by Medicare. This HIPAA format differentiation applies to the payment floor, but not to the ceiling.
A “paper claim” is submitted and received on paper, including fax print-outs. This also includes claims the carrier or FI received on paper and read electronically with OCR technology.
