Expert Tips to Ensure a Higher Clean Claims Submission Rate

Clean Claims Submission is the process of submitting medical insurance claims that meet all payer-specific, regulatory, and coding requirements so they are accepted and reimbursed on the first pass.

In Revenue Cycle Management (RCM), clean claims submission directly impacts cash flow by reducing denials, rework, and payment delays.

A clean claim contains accurate patient demographics, valid provider credentials, compliant CPT, HCPCS, and ICD-10 codes, and complete supporting data required by commercial insurers, Medicare, and Medicaid. High-performing medical practices maintain clean claims submission workflows that align with CMS guidelines, payer edits, and clearinghouse validation rules to achieve faster reimbursement and lower administrative costs.

Accurate Patient Registration and Eligibility Verification

The journey toward a successful Clean Claims Submission begins long before a provider sees a patient. Statistical data suggests that nearly 30% to 40% of all claim denials are rooted in front-end errors, specifically demographic mistakes and eligibility issues.

Prioritize Real-Time Eligibility (RTE)

Never assume a patient’s insurance coverage is the same as it was during their last visit. Payers frequently update their policies, and patients often change plans without notice.

To ensure a high Clean Claims Submission rate, your front-desk staff must perform real-time eligibility verification for every single encounter.

Pro-Tip: Utilize integrated EHR/PMS tools that automate eligibility checks 24–48 hours before the scheduled appointment. This allows time to contact the patient if there is a “COB” (Coordination of Benefits) issue or if a plan has been terminated.

Capture Precise Demographic Data

A missing middle initial, a misspelled street name, or an incorrect date of birth can trigger an immediate “Patient Not Found” rejection. Your staff should be trained to scan insurance cards (front and back) and verify the “Subscriber ID” versus the “Member ID” to avoid common pitfalls in the Clean Claims Submission workflow.

Mastery of Clinical Documentation and Medical Necessity

In the eyes of a payer, “if it wasn’t documented, it didn’t happen.” Clinical documentation is the bridge between the medical service provided and the reimbursement received.

Specificity in ICD-10-CM Coding

The transition to ICD-10 brought a level of granularity that requires providers to be highly specific. Vague codes (e.g., “unspecified” codes) are a primary reason for a failed Clean Claims Submission.

To improve your first-pass rate, documentation must support the highest level of specificity regarding laterality (left vs. right), encounter type (initial vs. subsequent), and etiology.

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Establishing Medical Necessity

Payers utilize “Local Coverage Determinations” (LCDs) and “National Coverage Determinations” (NCDs) to decide if a procedure is medically necessary.

If your diagnosis codes do not align with the procedure performed according to these policies, the claim will be denied. Providers must be educated on the link between clinical indicators and coding outcomes to facilitate a seamless Clean Claims Submission.

The Role of Advanced Claim Scrubbing Technology

Even the most diligent billing teams are human and prone to error. This is where technology becomes an indispensable ally. A “claim scrubber” is a software tool that audits a claim against thousands of payer-specific rules before it is sent to the clearinghouse.

Implementing Multi-Layered Scrubbing

To achieve a superior Clean Claims Submission rate, your software should check for:

• CCI Edits (Correct Coding Initiative): Ensuring that bundled codes are not billed separately (unbundling).

• MUEs (Medically Unlikely Edits): Catching clerical errors in “units of service” (e.g., billing 10 units of a drug when only 1 was administered).

• Payer-Specific Rules: Some payers require specific modifiers (like -25 or -59) in situations where others do not.

By identifying these errors at the pre-submission stage, you transform a potential denial into a successful Clean Claims Submission.

Addressing the Silent Killer: Provider Credentialing

One of the most overlooked aspects of a successful Clean Claims Submission strategy is provider credentialing and enrollment. If a provider is not properly “linked” to the practice’s Tax ID or if their CAQH profile has lapsed, every claim submitted for their services will be rejected or denied as “Provider Not Contracted.”

Proactive Credentialing Management

Credentialing is not a “set it and forget it” task. It requires constant maintenance.

• Re-attestation: Ensure CAQH profiles are updated every 90 days.

• Expiration Tracking: Monitor the expiration dates of DEA licenses, state medical licenses, and malpractice insurance.

• NPI Integrity: Ensure the NPI (National Provider Identifier) and Taxonomy codes on the claim match exactly what the payer has on file.

Inconsistent credentialing data is a frequent hurdle for Clean Claims Submission, yet it is entirely preventable with rigorous administrative oversight.

The Critical Use of Modifiers in Coding

Modifiers are the “adjectives” of the medical billing world; they provide extra context to a CPT code without changing its definition. However, the misuse of modifiers is a leading cause of audit flags and claim rejections.

Modifier -25 and -59 Accuracy

• Modifier -25: Used for a “Significant, Separately Identifiable Evaluation and Management Service” on the same day as a procedure.

• Modifier -59: Used to identify “Distinct Procedural Services.”

Payers often scrutinize these modifiers. If they are applied automatically by billing software without clinical justification in the notes, it will jeopardize your Clean Claims Submission rate. Educate your coding team to use modifiers only when the documentation supports the “separate and distinct” nature of the service.

Regular Staff Training and Feedback Loops

The medical billing landscape is fluid. CPT codes are updated annually, and CMS (Centers for Medicare & Medicaid Services) frequently changes reimbursement models (such as the shift toward Value-Based Care and MIPS).

Bridging the Gap Between Billing and Clinical Staff

A high Clean Claims Submission rate is only possible when the billing department and the clinical providers are in sync.

• Monthly Denial Reviews: Sit down with providers to show them why claims are being kicked back. If a provider consistently misses a specific documentation element, showing them the direct financial impact can encourage better habits.

• Ongoing Education: Invest in AAPC or AHIMA-certified training for your coders to keep them updated on the latest regulatory changes.

Monitoring Key Performance Indicators (KPIs)

To improve your Clean Claims Submission rate, you must first measure it accurately. You cannot manage what you do not measure.

Essential Metrics to Track

• First-Pass Clean Claim Rate: The percentage of claims paid on the first submission.

• Days in AR (Accounts Receivable): A high clean claim rate naturally lowers your Days in AR. Aim for under 35 days.

• Denial Rate by Payer: If one specific payer has a significantly lower clean claim rate than others, it may indicate a need for payer-specific rule updates in your scrubbing software.

Using a dashboard to visualize these metrics allows leadership to identify bottlenecks in the Clean Claims Submission process and deploy resources where they are needed most.

Effective Clearinghouse Utilization

The clearinghouse acts as the “middleman” between your practice and the insurance company. Selecting a high-quality clearinghouse is vital for a robust Clean Claims Submission workflow.

Real-Time Error Reporting

A top-tier clearinghouse provides immediate feedback. Instead of waiting weeks for a paper remittance advice (RA) to show a denial, a modern clearinghouse provides “277 Claim Status Category” codes within hours.

This allows your billing team to correct and resubmit errors instantly, maintaining the momentum of the Clean Claims Submission cycle.

Dealing with Telehealth and Modern Service Delivery

Since 2020, telehealth has become a staple of American healthcare. However, coding for telehealth remains a moving target.

Telehealth Coding Nuances

To ensure a Clean Claims Submission for virtual visits, you must use the correct Place of Service (POS) codes, typically POS 02 (Telehealth Provided Other than in Patient’s Home) or POS 10 (Telehealth Provided in Patient’s Home), along with modifiers like 95, GT, or FQ, depending on the payer.

Failure to align these codes with the specific payer’s temporary or permanent telehealth policies will result in immediate rejection.

The Importance of Timely Filing Limits

Every payer has a window of time during which a claim must be submitted. For Medicare, it’s usually one calendar year from the date of service, but many private payers (like UnitedHealthcare or Cigna) have limits as short as 90 or 180 days.

Avoiding “CO-29” Denials

A claim submitted past the filing limit is a lost cause; it cannot be appealed successfully unless there is proof of a primary payer delay.

A disciplined Clean Claims Submission strategy involves submitting claims within 24-48 hours of the date of service to ensure that even if a claim is rejected, there is ample time to correct and resubmit within the filing window.

The Bottom Line

Achieving a high Clean Claims Submission rate is not an overnight task. It requires a commitment to excellence at every touchpoint of the patient journey, from the first phone call to the final adjudication.

By focusing on front-end accuracy, leveraging intelligent technology, and maintaining rigorous provider credentialing, your practice can significantly reduce its denial rate and ensure a steady, predictable cash flow.

In the world of medical billing, “clean” doesn’t just mean “error-free”, it means “optimized for success.” Start implementing these tips today to turn your Clean Claims Submission process into a competitive advantage.

FAQs: Clean Claims Submission Rate

 

What is a good Clean Claims Submission rate?

In the healthcare industry, a rate of 95% or higher is considered excellent. Anything below 90% suggests significant issues in either the front-end registration or the coding process that need immediate attention.

How does “Clean Claims Submission” affect patient satisfaction?

When claims are submitted cleanly, patients receive accurate “Explanation of Benefits” (EOB) statements faster. This prevents “surprise billing” and reduces the need for patients to call the office to resolve insurance disputes, leading to a better overall patient experience.

Can an EHR guarantee a 100% Clean Claims Submission rate?

No software can guarantee 100% accuracy because software is only as good as the data entered into it. While an EHR/PMS provides the tools (like scrubbers), human oversight in clinical documentation and credentialing is still essential.

Why is credentialing linked to Clean Claims Submission?

Insurance companies will only pay “clean” claims if the provider is officially recognized in their system. If the provider’s data is missing or outdated in the payer’s database, the claim is considered “dirty” or “invalid” upon receipt, regardless of how accurate the coding is.

How often should we update our claim scrubbing rules?

Claim scrubbing rules should be reviewed and updated at least quarterly. Payers often change their internal “edits” and reimbursement policies without widespread notification, so staying proactive is key to maintaining your Clean Claims Submission rate.