Know State and Payer Rules for Clean Claims

Filing a clean claim gives you protections under Texas’ prompt pay law (from payers that are subject to the law). For a claim to be “clean” you don’t have to fill out every field on the 837 electronic claim form or the CMS-1500 paper form, just the right ones.

Texas Department of Insurance (TDI) regulations define clean claims. TDI has specified which fields are required for a claim to be considered clean, which fields are conditional, and which fields are optional under the regulations. The Texas Insurance Code at 28 TAC §21.2803, Elements of a Clean Claim, contains these definitions. 

In addition, be familiar with each of your contracted health plans’ specific requirements for elements or attachments of a clean claim. A health plan may require these additional items by written notice in your provider manual or other claims filing instructional documents, or by your contract with the HMO or preferred provider organization. 

You must satisfy all requirements of the TDI rules and the health plan’s additional requirements to have a clean claim. Carefully read your contract, provider manual, or other claims filing instructional documents and any amendments for additional elements and attachments.

Some additional tips:

  • Every clean claim starts with good documentation of the patient encounter, accurate coding, and required preauthorizations.
  • Configure your practice management system to ensure all required clean claim elements are validated (work with your vendor if necessary).
  • Instruct your clearinghouse to reject claims that don’t meet clean claim rules. 
  • Retain copies of the claim as submitted.
  • Save transmission acknowledgement reports and transactions for four years (under the prompt pay law you have up to four years to notify a payer that a claim is late or underpaid). 
  • Track payer denials so you can identify avoidable errors.

You can learn more about prompt pay and clean claims in with these two on-demand webinars in the TMA Education Center. Additionally, TMA has many other resources to help you get paid.

Published April 26, 2016

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