Clean Claim Submission Checklist

CLEAN CLAIM SUBMISSION CHECKLIST ═══════════════════════════════════════ SECTION 1: PATIENT INFORMATION VERIFICATION ═══════════════════════════════════════ 1.1 DEMOGRAPHICS [ ] Patient full legal name matches insurance card exactly [ ] Date of birth verified against insurance record [ ] Gender marker matches payer file (affects code validation) [ ] Current address on file (required for some state Medicaid programs) 1.2 INSURANCE VERIFICATION [ ] Insurance ID and group number confirmed [ ] Subscriber relationship code correct (self, spouse, child, other) [ ] Coordination of benefits checked for dual coverage [ ] Payer ID confirmed for electronic submission 1.3 ELIGIBILITY [ ] Eligibility verified for the date of service (not just current date) [ ] Plan benefits confirmed for the service type [ ] Copay, coinsurance, and deductible amounts noted [ ] Out-of-network status checked (if applicable) ═══════════════════════════════════════ SECTION 2: CODING REVIEW ═══════════════════════════════════════ 2.1 CPT/HCPCS ACCURACY [ ] Procedure codes match the documented service [ ] Codes are current for the date of service (no retired codes) [ ] Units are correct (time-based codes calculated per payer rules) [ ] Unlisted codes include required documentation 2.2 ICD-10 ACCURACY [ ] Primary diagnosis supports medical necessity for each procedure [ ] Diagnosis specificity is at the highest level available [ ] Diagnosis codes are valid for the date of service [ ] Code sequencing follows payer guidelines 2.3 MODIFIER CHECK [ ] Modifiers are clinically supported and documented [ ] Modifier order follows payer-specific sequencing rules [ ] NCCI edit pairs checked (modifier 59 or X-modifiers applied only when distinct) [ ] Bilateral, multiple procedure, and add-on code modifiers verified 2.4 NCCI EDITS [ ] Code pairs checked against current NCCI edit table [ ] Column 1/Column 2 conflicts resolved before submission [ ] Medically Unlikely Edits (MUE) unit limits verified [ ] Add-on codes paired with valid primary codes ═══════════════════════════════════════ SECTION 3: CHARGE ENTRY ═══════════════════════════════════════ 3.1 FEE SCHEDULE [ ] Charges match your contracted or published fee schedule [ ] Fee schedule is current (updated for the calendar year) [ ] Medicare rates cross-referenced for benchmark validation 3.2 UNITS AND CHARGES [ ] Units match documentation (especially time-based codes) [ ] Total charges calculated correctly [ ] Sales tax applied if required by state for certain supplies 3.3 PLACE OF SERVICE [ ] POS code matches where the service was rendered [ ] Telehealth POS code correct (02 vs. 10 per payer rules) [ ] Facility vs. non-facility rate applied correctly based on POS ═══════════════════════════════════════ SECTION 4: PRE-SUBMISSION ═══════════════════════════════════════ 4.1 PROVIDER INFORMATION [ ] Rendering provider NPI is correct and active [ ] Billing provider NPI matches the entity on the payer contract [ ] Referring provider NPI included (required for many specialties) [ ] Provider taxonomy code current 4.2 CLAIM FORM COMPLETENESS [ ] All required fields populated (no blank required boxes) [ ] Prior authorization number included (if PA was required) [ ] Accident or injury date included (if applicable) [ ] Onset date included for chronic conditions (if required by payer) 4.3 TIMELY FILING [ ] Claim is within the payer's timely filing limit [ ] If resubmission: original claim reference number included [ ] If corrected claim: frequency code 7 indicated [ ] Filing deadline calendared with 10-day buffer for rejections