A claim is an invoice that the clinic submits to a payer to get paid for the services (charges) performed. Most payers require that the invoices (claims) be submitted to them be in a certain format. Some require that if the invoice contains a specific service (charge) that additional documentation should be submitted. Administrators must have someone on their staff who is aware of these requirements. In addition to these requirements, individual states have their own rules regarding these claims. Knowledge and the preparation taken in the steps prior to this are the only ways to optimize this step in the revenue cycle.
To receive payment from a payer in a prompt manner, clinics must submit a claim free of mistakes and errors. This is usually termed submitting a “clean claim.” 42 CFR 447.45 defines a clean claim as one that needs no additional documentation from the service provider or third party. Below is a list of links to state’s insurance codes regarding claims. Almost all states now have some sort of “prompt payment” regulation. Some of these regulations have definitions regarding clean claims that are to be submitted to insurance companies. Those marked below do not have a specific definition.