ATT019_SurvivorCCE_TGD010_CleanClaims.pdf

Controlled Unclassified Information TGD 010 March 2023

General Contractor Technical Guidance Document

TGD #010

Clean Claim Definition

ORIGINAL PUBLICATION: February 28, 2020 DATE LAST REVIEWED: March 14, 2023

Purpose To provide clarification on the definition of a “Clean Claim.”

Stakeholders Affected Clinical Centers of Excellence (CCE): Responsible for reviewing external claims and submitting internal and external claims to the HPS/TPA contractor.

Nationwide Provider Network (NPN): Responsible for reviewing and adjudicating claims from NPN providers.

CCE External Providers: Responsible for submitting claims to HPS/TPA contractor for CCE review and adjudication.

Health Program Support Contractor or Third-Party Administrator (HPS/TPA): Responsible for adjudicating claims from CCEs and CCE External Providers.

Background The Centers for Medicare & Medicaid Services (CMS) defines a clean claim as follows: a clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment.2 Claims adjudication and prompt payment timelines are initiated based on the receipt of a clean claim. A provider submits a clean claim by providing the required data elements on the standard claim forms, along with any attachments and additional elements, or revisions to data elements, attachments, and additional elements, of which the provider has knowledge.

Technical Guidance Required Elements of a Clean Claim Claims for inpatient and institutional treatment and services are to be submitted on the UB-04 (also known as CMS-1450) and claims for individual professional procedures and services are to be submitted on the CMS-1500. These forms were developed by CMS to process and generate provider reimbursement. The required elements of these forms (and of a clean claim) must be complete, legible, and accurate.

WTC Health Program guidelines may supersede these requirements. In addition, claims may be submitted electronically through the HPS, Fire Department New York (FDNY), Nationwide Provider Network (NPN)/William Street Clinic (WSC) and Change Healthcare. The WTC Health Program does not typically but may require attachments or other information in addition to these standard forms (as noted below). The Program may request treatment records for review. Paper claims may be accepted for CCE/NPN submittals and for all dental claims.

Definition of a Clean Claim

A clean claim under the WTCHP meets the following criteria (also see Appendix A):

• Meets all the detailed elements required as described in Appendix A

• The healthcare provider is licensed to practice on the date the member received the service (date of service) and is not under investigation for fraud.

• The claim form:

o Includes all the required information as outlined in Appendix A below, and o Correctly identifies the payer and includes the right payer identification number and payer mailing address.

• The codes listed on the claim:

o Are International Classification of Diseases 10th Revision (ICD-10) o Contain a procedure, or applicable revenue code for services rendered o Are associated with allowable diagnostic codes in the WTC Health Program

Diagnostic Codebook and relevant treatment care suites, based on a member’s approved certified conditions (e.g., ancillary condition coverage), and o Have at least one supporting diagnosis code for which the member has an approved certification and benefit authorization at the time of service.

The following components of a submitted claim are not factored into the definition of a clean claim:

• EFT/ACH information (e.g., incomplete or inaccurate information)

• Coordination of benefits

• Timely filing limits and claim review time limits (TGD007)

Quality Controls Program may request claim report to include “clean claim” date. The Program may request additional records, reports relating to clean claims, and perform ad hoc audits.

Claims Submission

• The CCE/NPN should review all claims and accurately identify claims as clean or unclean based on the guidance in this TGD.

• The CCE/NPN should monitor claims and internally report on unclean claims; trends in unclean claims should be used to identify areas of opportunity and to proactively address and prevent unclean claims from being submitted.

Claims Adjudication

• The TPA/NPN should monitor claims and internally report on unclean claims; trends in unclean claims should be used identify areas of opportunity and to proactively address and prevent unclean claims from being submitted.

• The TPA/NPN should work with the providers in network to increase the percentage of electronic claims. Providers routinely submitting paper claims should receive outreach and education on submission of electronic claims.

• Paper claims should undergo additional QA/QC to ensure accuracy and completeness.

Supplemental Material(s) PWS Section on Claims Submission and Payment

TGD007

Revision History

Rev # Changes Made to Document Date

1 New Document 02/28/2020

2 Revision 12/03/2021

3 Update to 2022 TGD Template 07/01/2022

Delete criteria “the healthcare provider is enrolled in the WTC Health Program” Clarify definition of a clean claim Add criteria specifying the components of a submitted claim are not factored into the definition Add quality controls

3/14/2023

WTC Health Program Approval

The undersigned acknowledges they have reviewed this WTC Health Program technical guidance document (TGD) and agree with the approach it presents. Changes to this TGD will be coordinated with and approved by the undersigned or their designated representative(s).

Signature: ______________________________________________ Date: ____________

Appendix A

Situational Elements of a Clean Claim Unless otherwise agreed by contract, the data elements contained in this paragraph are necessary for claims filed by physicians or providers if circumstances exist which render the data elements applicable to the specific claim being filed. The applicability of any given data element contained in this paragraph is determined by the situation from which the claim arose.

Other insureds or enrollee’s name (CMS-1500, field 9), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in CMS- 1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.

Other insureds or enrollee’s policy/group number (CMS-1500, field 9a) is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in paragraph CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.

Other insured or enrollee date of birth (CMS-1500, field 9b), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in paragraph CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.

Other insured or enrollee plan name (employer, school, etc.) (CMS-1500, field 9c), is applicable if patient is covered by more than one health benefit plan. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.

Other insured or enrollee HMO or insurer name. If the essential data element specified in CMS-1500, field 11d, “disclosure of any other health benefit plans,” is answered yes, this is applicable.

Subscriber’s plan name (employer, school, etc.) (CMS-1500, field 11b) is applicable if the health benefit plan is a group plan.

Prior authorization number (CMS-1500, field 23), is applicable when prior authorization is required.

Whether assignment was accepted (CMS-1500, field 27), is applicable when assignment has been accepted.

Amount paid (CMS-1500, field 29), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber or by a primary plan (Commercial or Medicare). When applicable, a copy of the primary plan’s EOB is required.

Balance due (CMS-1500, field 30), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber.

Pay To name, address, and ID (UB-04, field 2), required when the Pay To information is different than Billing provider info in field 1.

Medical/ health record number (UB-04, field 3b), not the same as 3a.

Discharge hour (UB-04, field 16), is applicable if the patient was an inpatient, or was admitted for outpatient observation.

Condition codes (UB-04, fields 18-28 are applicable if the CMS UB-04 manual contains a condition code appropriate to the patient’s condition.

Occurrence codes and dates (UB-04, fields 31-34), are applicable if the CMS UB- 04 manual contains an occurrence code appropriate to the patient’s condition.

Occurrence span code, from and through dates (UB-04, field 35-36), is applicable if the CMS UB-04 manual contains an occurrence span code appropriate to the patient’s condition.

Non-covered charges (UB-04, field 48), required when applicable.

Prior payments – payer and patient (UB-04, field 54), is applicable if payments have been made to the physician or provider by the patient or another payer or subscriber, on behalf of the patient or subscriber, or by a primary plan.

Diagnoses codes other than principal diagnosis code (UB-04, fields 67A-Q), is applicable if there are diagnoses other than the principal diagnosis and ICD-10 code is required effective 10/1/15;

Principal procedure code and date (UB-04, field 74), required on inpatient claims when a procedure was performed.

Other procedure codes and dates (UB-04, field 74a-e), required on inpatient claims when additional procedures must be reported.

o Ambulance trip report will be requested if needed o Anesthesia report will be requested if needed.

Additional clean claim elements: In the event information not specified herein is required to make an accurate determination of proof of loss, the provider will be notified in writing within the applicable regulatory or contractual prompt payment standards. The notice will identify the specific claim or portion of a claim that is being reviewed and the information required. The review is completed within the applicable prompt payment standard following receipt of the information requested from the provider.

Date2_af_date: 3/14/2023