CurrentArizona Complete HealthPolicy CC.PI.04

Clean Claim Reviews

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.

Policy Summary

PayerArizona Complete Health

PolicyClean Claim Reviews

Policy CodePolicy CC.PI.04

Change TypeNo material changes

Effective DateNov 1, 2012

Next Review Date

Key ActionRequest medical records when necessary and send a Claim Review Report listing exceptions to the provider while paying the clean portion per findings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>$25,000prepayment inpatient claim threshold (best practice)

Allpolicy applies to products

Multipledocument review history

10+facility charge categories

Clean Claim Review Criteria

Clean claim review criteria

Policy Summary

PayerArizona Complete Health

PolicyClean Claim Reviews

Policy CodePolicy CC.PI.04

Change TypeNo material changes

Effective DateNov 1, 2012

Next Review Date

Key ActionRequest medical records when necessary and send a Claim Review Report listing exceptions to the provider while paying the clean portion per findings.

SourceLink

On This Page

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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).

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.

Workflow and Provider Interactions

Documentation Required

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

Clean claim review — definition

DefinitionClean claim reviews are conducted on claims selected by referral criteria using the itemized bill; medical records are requested when necessary to evaluate billing compliance and determine the clean portion for payment.

Review basisAssessment against CMS, Health Plan Benefits, and applicable state Medicaid coverage and billing standards (including Uniform Billing Editor).

OutcomeA Claim Review Report listing exceptions is sent to the provider and the clean portion is paid per findings.

High-dollar review — definition and referral examples

DefinitionHigh-dollar review referral criteria (best practice): referrals for claims requiring additional prepayment scrutiny based on monetary or clinical outlier indicators.

Monetary criterionPrepayment inpatient claims with payable charges > $25,000.

Clinical/outlier criterionInpatient claims that hit a DRG outlier.

Catch-allAny other concerning claims identified by referral criteria for additional review.

OpenPayer

Clean Claim Reviews

Clean Claim Review Criteria

Billing and Coding References

Workflow and Provider Interactions

Key Definitions