A clean claim is a submitted claim without any errors or other issues, including incomplete documentation that delays timely payment.

There are several required elements for a clean claim, and medical bills are denied if elements are incomplete, illegible, or inaccurate. A clean claim meets all the following requirements:

· Identifies the health professional, health facility, home health care provider or durable medical equipment provider who provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.

· Sufficiently identifies the patient and health plan subscriber.

· Lists the date and place of service.

· Is a claim for covered services for an eligible individual?

· If necessary, substantiates the medical necessity and appropriateness of the service provided.

· If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.

· Identifies the service rendered using a generally accepted system of procedure or service coding.

· Includes additional documentation based upon services rendered as reasonably required by the health plan.

A dirty claim is a claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment.

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