What is a dirty claim?

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asked Jul 20, 2023 in Insurance by RBurgess (1,260 points)
What is a dirty claim?

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answered Dec 22, 2023 by Alexxa12901 (3,320 points)
A dirty claim is a claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment”.

Unclean claim means a claim that has not been properly completed according to Medicaid's billing guidelines, including a claim that is not accompanied by the necessary documentation required by state law, federal law, or state administrative rule for payment.

A claim submitted with errors, one requiring manual processing for resolving problems, or one rejected for payment.

A payor rejection is considered a “dirty claim” as it was returned by the payor prior to processing.

However, sometimes claims can go all the way through the adjudication process without the required numbers only to end up in a denied state.

A clean claim is one that must be submitted with no inconsistencies or other factors, such as insufficient documentation, that would prevent payment.”

A clean claim requires numerous elements, and medical bills are turned down if any of these elements are unaccounted, incomprehensible, or inaccurate.

While incorrect coding in a claim will almost certainly lead to denial, coding itself is only one piece of the clean claims puzzle.

Administrative deficiencies can also lead to denied claims.

It's important strategically to take a holistic approach to claims management that prioritizes clean claim submission.

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