CurrentFidelis CarePolicy FC.PP.036

Clean Claim Reviews

Defines the requirements and process Fidelis Care (Centene/Health Plan) uses to review institutional (facility/hospital) billed charges for clean claim determination and payment; applies to institutional providers and applicable Health Plan contracts.

Policy Summary

PayerFidelis Care

PolicyClean Claim Reviews

Policy CodePolicy FC.PP.036

Change TypeNo material changes

Effective Date11/2012

Next Review Date

Key ActionPerform clean claim reviews on eligible institutional claims using the itemized bill and request medical records when necessary; pay clean portions per recommendation within timely payment requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

S25,000inpatient payable charge threshold (best practice)

timelyclean portion paid within

Institutional providersapplication scope

Itemized billprimary document

Clean Claim Review Criteria and Process

Clean claim review criteria and process

Claims are reviewed against referral criteria and billing/compliance criteria; eligible institutional claims undergo clean claim review using the itemized bill and may require medical records. Clean portions are paid per the review recommendation.

ALL of the following

Referral criteria (any of):
- Inpatient claims with payable charges >= $25,000
- Inpatient claims that hit DRG outlier or other concerning claims
- Prepayment inpatient claims

Eligible claims undergo a clean claim review using the itemized bill; medical records are requested when the reviewer finds it necessary

Policy Summary

PayerFidelis Care

PolicyClean Claim Reviews

Policy CodePolicy FC.PP.036

Change TypeNo material changes

Effective Date11/2012

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Key categories of errors and discrepancies (any):

Experimental/investigational treatments or items that are not reimbursable
Billing errors (e.g., duplicate billing, excessive markups, data entry errors, inappropriate intervals, component of a primary procedure, billing >24 hours for a daily therapy)
Incorrect bill type (charges submitted on wrong bill type)
Insufficient description to properly evaluate the charge
Incorrect charges (price or quantity discrepancies)
Level of care not supported by patient acuity
Services not authorized when authorization is required
Non-covered items per the Health Plan benefit
Quality of care issues (never events, hospital-acquired conditions)
Unbundling of routine or integral components that are not separately billable on inpatient claims

Workflow, Provider Interactions, and Referral Criteria

Prior Authorization

High-dollar / Prepayment Referral Criteria

High-dollar and prepayment referral criteria trigger referral of inpatient claims for focused review. The Company reviews all hospital claims against these criteria to determine eligibility for high-dollar review. Typical referral criteria (best practice; plan-specific criteria may apply) include: inpatient claims with payable charges ≥ $25,000; inpatient claims identified as DRG outliers; and other concerning claims warranting prepayment review. When a claim meets referral criteria, it is routed for a clean claim review that uses the itemized bill as the primary source; medical records are requested only when the reviewer determines they are necessary.

Inpatient claims with payable charges ≥ $25,000
Inpatient claims that trigger DRG outlier review
Other concerning claims flagged for prepayment review
Plan-specific referral thresholds may apply

Documentation Required

Workflow and Provider Interactions

Provider actions and documentation expectations during clean claim review: submit an itemized bill with claims — the clean claim review is performed using the itemized bill. If requested, supply medical records, invoices, doctor orders, provider contracts, or other clinical/billing documentation necessary to resolve billing exceptions. Providers should ensure billing complies with CMS, Health Plan Benefits, and applicable state Medicaid coverage; charges represent reimbursable benefits under the member’s plan; and billed charges reasonably and consistently relate to underlying costs (per CMS Provider Reimbursement Manual §2203). The Company will send a Claim Review Report listing exceptions to the provider/facility; the clean portion of the claim will be paid within timely payment requirements. If documentation during resolution clears exceptions, unpaid charges will be paid to the provider at that time.

Always submit a complete itemized bill with sufficient detail to evaluate charges
Provide medical records or supporting documentation promptly when requested to clear exceptions
Ensure charges are allowable under the member’s plan and billed in accordance with CMS/Medicaid and plan billing guidelines
Avoid common billing errors (duplicate billing, incorrect bill type, unbundling, excessive markups, incorrect quantities) to reduce denial/recovery risk
Respond to Claim Review Reports and appeals with requested documentation to enable timely resolution and payment

Defined Terms

Health Plan

Health Plan definitionA health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or an affiliate.

Scope of policy applicationApplies to Health Plans that adopt this payment policy for making coverage and payment determinations and administering benefits.

Policy status noteThis payment policy is effective as of the date determined by the Health Plan and may be changed, amended, or withdrawn by the Health Plan.

Clean claim review

Clean claim review (definition)Evaluation of facility billed charges using the itemized bill to identify exceptions (billing errors, non‑covered items, unbundling, level‑of‑care discrepancies, etc.), request medical records as needed, and produce a Claim Review Report.

Primary source documentItemized bill used as the basis for the clean claim review and to identify exceptions.

Outcome and provider communicationA Claim Review Report listing exceptions is sent to the provider/facility; clean portions are paid per the clean claim recommendation within timely payment requirements.

Records and resolutionMedical records, invoices, orders, contracts or other clinical information may be requested to clear exceptions; unpaid charges may be paid if exceptions are resolved during the resolution process.

OpenPayer

Clean Claim Reviews

Clean Claim Review Criteria and Process

Billing, Coding, and High-Dollar Thresholds

Workflow, Provider Interactions, and Referral Criteria

Defined Terms