Clean Claim Reviews
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Defines requirements and procedures for reviewing facility-billed charges for clean claim determination; applies to Centene Corporation, its affiliates, health plans, and subsidiary companies and their employees involved in payment integrity and claims processing.
No material clinical or coverage changes in this revision.
Clean Claim Review Criteria
Clean claim review criteria
Claims selected by referral criteria are reviewed using itemized bills and, when necessary, medical records. Reviews evaluate billing against CMS, state Medicaid coverage, and Uniform Billing Editor standards. Specific criteria include:
ALL of the following
Referral triggers (any of the following):
- Prepayment inpatient claims with payable charges greater than $25,000
- Inpatient claims that hit a DRG outlier
- Any other concerning claims
- Selected claims are reviewed using the itemized bill; medical records are requested when the reviewer finds it necessary.
ALL of the following
- Provider billing must comply with CMS, applicable Health Plan benefits, and applicable state Medicaid coverage.
- Billed charges must reasonably and consistently relate to the provider's underlying costs (CMS Provider Reimbursement Manual Section 2203).
- Charges must constitute reimbursable benefits under the applicable plan.
- Charges must comply with Billing Guidelines in the CMS Provider Reimbursement Manual and the Uniform Billing Editor; specifically, the billed acuity level (revenue code) must comply with the resource consumption threshold specified in the Uniform Billing Editor.
ALL of the following
Examples include (any of the following):
- Billing errors (e.g., pharmaceutical and implant markups exceeding eight times presumed cost, duplicate billing, data keying errors, inappropriate interval, component of a primary procedure, more than 24 hours of a daily therapy billed).
- Experimental or investigational services/drugs not reimbursable under plan language.
- Incorrect bill type (charges submitted on wrong bill form).
- Incorrect charges (discrepancy in price or quantity billed).
- Insufficient description (service/item lacks detail to evaluate).
- Level of care not supported by patient's acuity level.
- Non‑covered services/items under the Health Plan benefit.
- Not authorized when authorization is required.
- Quality of care issues (never events and hospital‑acquired conditions).
- Unbundling (supplies/services that are routine, built into room & board, or integral components of another procedure and not separately billable on inpatient claims).
ALL of the following
- A Claim Review Report listing all exceptions is sent to the Provider/Facility; the Company pays the clean portion of the claim per the clean claim review recommendation within timely payment requirements.
- Responses to appeals are provided as necessary; if billing exceptions are resolved during the resolution process with medical records, invoices, orders, contracts, or other clinical information, unpaid charges will be paid at that time.
Billing and Coding References
| References revenue codes/rev code acuity level compliance with Uniform Billing Editor and CMS Provider Reimbursement Manual requirements |
Workflow and Provider Interactions
Provider responsibilities during clean claim review — documentation requests, timelines, and resolution
Claims meeting referral criteria (e.g., prepayment inpatient claims > $25,000, inpatient DRG outliers, or other concerning claims) will be selected for clean claim review using the itemized bill; medical records will be requested when the reviewer determines they are necessary. A Claim Review Report listing all exceptions will be sent to the provider/facility, and the Company will pay the clean portion of the claim per the clean claim review recommendation subject to timely payment requirements. During appeals/resolution, unpaid charges may be paid if exceptions are cleared with submitted medical records, invoices, orders, contracts, or other clinical information.
- Referral criteria (best practice): prepayment inpatient claims > $25,000, inpatient claims that hit DRG outlier, or other concerning claims. [6]
- Reviews performed using the itemized bill; medical records requested when necessary. [6]
- Claim Review Report sent to Provider/Facility listing exceptions; clean portion paid per findings and timely payment rules. [7]
- During resolution, unpaid charges will be paid if billing exceptions are cleared with medical records, invoices, orders, provider contracts, or other clinical information. [7]
Key Definitions
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