Definition of Clean Claim
A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.
The following bullets are some examples of what are considered clean claims:
• Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);
• Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).
• Claims not approved for payment by CWF within 7 days of the FI’s original claim submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF system/communication difficulties);
• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;
• Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carrier’s or FI’s instructions;
• Are developed on a postpayment basis; and,
• Have all basic information necessary to adjudicate the claim, and all required supporting documentation
A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.
The following bullets are some examples of what are considered clean claims:
• Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);
• Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).
• Claims not approved for payment by CWF within 7 days of the FI’s original claim submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF system/communication difficulties);
• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;
• Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carrier’s or FI’s instructions;
• Are developed on a postpayment basis; and,
• Have all basic information necessary to adjudicate the claim, and all required supporting documentation
C. Bills Returned to Provider
If the carrier or FI returns the bill and retains a claim record to minimize data entry cost when returned, the receipt date is corrected when the bill is properly completed and passes carrier or FI edits.
D. Bills Requiring Medical Information
When a carrier or FI requests medical documentation, it retains the bill as a pending record until it either pays, denies, or rejects (in the case of FIs) it. Returning cases for review by the PRO is not a request for medical documentation. Claims that fail initial carrier or FI edits because required medical reports or other required attachments are not included are also not requests for medical documentation.
E. Adjustment and Cancel Bills
An adjustment request bill is a correction to a claim previously processed. The carrier or FI establishes a control record for it.
The carrier or FI counts adjustments as received and pending only when they pass carrier or FI edits. The carrier or FI assigns the date received in its mailroom as the receipt date for hospital and MSP adjustment requests.
The carrier or FI counts adjustment bills as processed when no further action by it is required. The final action taken on the adjustment request bill depends upon the situation.
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