If your Clean Claim Rate (CCR) is below 95%, it means your healthcare practice is losing revenues moreover increasing expenses due to rejected claims. Note that the first submission is what determines the percentage of clean claim rate (CCR). To run a profitable healthcare practice, achieving 95% or above clean claim rate is essential.

Clean Claim Submission Guidelines

Billing - Electronic Form Submission

Use of Electronic from instead of Paper form for medical claim submission can eliminate some of the top rated denials and rejections such as incorrect details, missing details, Spelling and format issues. Since Electronic form are standardised and has built in mechanism to check for errors can eliminate such errors before the claim is submitted.

Eligibility And Prior Verification

Due to different circumstances such as getting unemployed or laid off, employment status change, or Insurance expired the cover of the insurance might not be there. Also, sometimes, patient may have the insurance cover, but the procedure or service he is given may not be covered or eligible in that insurance plan.
So it is important that, Eligibility and prior verification is carried out and any change in patient recent circumstances is documented and verified. If the service/procedure is not covered by the plan, the claim can be rejected or insurance can put that part under Patient responsibility (PR) under Claim Adjustment Reason Codes (CARC).

Complete And Well Managed Patient Documentation

To achieve 95% or higher clean claim, it is also important that patient record is complete, detailed, accurate and well managed. Normally, if the Documentation is not complete such as Doctor note, medically necessity, prior authorisation is not part of the claim where one or all of them is required.
The claim can be rejected or denied. It also means that all the patient documentation is kept in well organised and secured manner so accessibility by authorised personal is not an issue and claim is sent with all the required claim supplemental information.

Precise, updated and correct Information

Having the patient information in the system does not mean that it has not changed. Patient name, address, insurance details, primary, secondary or tertiary can change any time. Having the most updated, precise and correct information in the Healthcare Practice Management softwares is paramount to avoid claim rejections and Denials.
The best practice is to validate and confirm all the patient information at the time or appointment booking or prior to patient visit to save time. Correct demographics and accurate patient information is vital in medical billing and efficient RCM.

Insurance/Payer and Coding guidelines

Guidelines are the blood line of each Claim. It is very important to stay updated with the payers guidelines as they can change same as coding Guidelines changes. ICD-10-CM, HCPS Level II, CPT guidelines updates every year and if the claim is made per the previous guidelines, it will be rejected or denied. On top of that, Certain insurances has their own Coding, for example, Capital Blue Cross has it’s own code for annual GYN exams.
Payer guidelines such as, Paper or Electronic form, Deadlines of submission, what documents are required at the time of submission, what additional details to go into the Claim are vital to know to achieve the Clean claim submission.

Correct Interpretation And Accurate Coding, Modifiers

Coding Drives the Medical billing as both are different but important in making the claim successful makes the RCM more efficient. The correct interpretation of Doctors/Providers note is important as wrong interpretation can cause the wrong coding or mismatch of ICD and CPT Codes and this mismatch can cause the claim rejection or denial.
Correct coding itself is very important along with the use of modifier. Sometimes, claim can be denied on the use of wrong modifiers, if bundling is not use correctly, or Global time period is not catered precisely. Efficient Medical billing process is dependent on right coding and if coding is not correct the claim is likely to Deny.

Clean Claim Information Requirements

For Clean claim, required fields on the paper form (CMS 1500) or electronic from (837p) must be filled correctly with updated information otherwise claim will be denied.
Health care professional details, service facilities details (facility billing address, provider NPI and name), Durable medical equipment provider details if necessary, billing tax ID and Billing NPI.
Patient or subscriber insurance details, insurance ID, patient and/or subscriber demographics (name, address).
Document stating the appropriateness of services or medically necessity. Place of service and date of service.
Prior authorisation document attached with prior Auth number if necessary. Correct codes, including Diagnosis (ICD-10-CM), procedural (CPT), Durable medical equipment (HCPCS Level II). Any other documentation required by the insurance on specific claim.

If you would like your practice to achieve the Clean Claim Rate (CCR) 98% or above, please get in touch with us at info@mtservices.pro