Clean Claim. Definition
Clean Claim. A claim that: (1) has no defect, impropriety, lack of any BCBSM required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment; and (2) otherwise conforms to the clean claim requirements for equivalent claims under original Medicare.
Clean Claim. As defined by Miss. Code Xxx. § 83-9-5, a Clean Claim refers to a claim received by an insurer for adjudication and which requires no further information, adjustment or alteration by the provider of the services or the insured in order to be processed and paid by the Contractor.
Clean Claim. A claim for payment for a health care service, which has been received by ACDE, has no defect or impropriety. A defect or impropriety shall include a lack of required substantiating documentation or a particular circumstance requiring special treatment that prevents timely payment from being made on the claim. Consistent with 42 CFR §447.45(b), the term shall not include a claim from a health care provider who is under investigation for fraud or abuse regarding that claim, or a claim under review for medical necessity.
Clean Claim. Definition
2 4.1 TERM
Clean Claim. A Clean Claim means a claim for payment for Contracted Services that contains all the required data elements necessary for adjudication, without requesting supplemental information from the submitter, as required by the VA CCN Requirements.
Clean Claim. A Claim that can be processed without obtaining additional information of the service from the provider or the provider’s designated representative as further defined in the HMSA QUEST Participating Provider Handbook.
Clean Claim. A Claim submitted by a physician or Provider for health care services rendered to an Enrollee, with the data necessary for the STAR+PLUS MMP or subcontracted Claims processor to adjudicate and accurately report the Claim. A Clean Claim other than a Nursing Facility Unit Rate Clean Claim must meet all requirements for accurate and complete data as defined in the appropriate Claim type Encounter guides as follows:
1.25.1. 837 Professional Combined Implementation Guide;
1.25.2. 837 Institutional Combined Implementation Guide;
1.25.3. 837 Professional Companion Guide;
1.25.4. 837 Institutional Companion Guide; or
1.25.5. National Council for Prescription Drug Programs (NCPDP) Companion Guide
Clean Claim. Unless otherwise defined by any applicable Federal or State law, rule, or regulation (which definition then shall be controlling), a Claim submitted by Provider pursuant to this Agreement that can be processed and determined without obtaining additional information from the provider or from a third party and which does not involve coordination of benefits, third party liability or subrogation or any material defect or error that prevents timely adjudication. A Claim from Provider, who is under investigation for fraud or abuse or a Claim under review for medical necessity, is not a Clean Claim or Complete Claim.
Clean Claim. In accordance with 42 CFR 447.45, a Claim that can be processed without obtaining additional information from the provider of the service or from a third-party. 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, Waste or Abuse, or a Claim under review for Medical Necessity.