Clean Claim Reviews
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Defines requirements and procedures for evaluating facility (hospital) billed charges through clean claim reviews; applies to Centene Corporation, its affiliates, health plans, and subsidiary companies and staff involved in payment integrity and claims processing.
No material clinical or coverage changes in this revision.
Clean Claim Review Criteria
Clean claim review criteria and actions
Claims are reviewed for eligibility for clean claim review and evaluated against billing, coding, and clinical criteria including but not limited to the following:
Referral criteria
- Pre-payment or Post-payment inpatient claims with payable charges > $25,000
Best-practice threshold; plan-specific criteria may apply.
- Inpatient claims that hit a DRG outlier or a specified percent of billed charges
- Any other concerning claims as identified by adjudication or review workflows
Documentation basis
- Itemized bill required for clean claim review
Clean claim review is performed using the itemized bill.
- Provider medical records, invoices, doctor orders, provider contracts or billing policies or other clinical information may clear exceptions
If exceptions are cleared during resolution, unpaid or recovered charges will be paid at that time.
Billing & coding compliance
- Provider billing complies with CMS, Health Plan Benefits, and applicable state Medicaid coverage
- Provider billed charges must reasonably and consistently relate to underlying costs (CMS Provider Reimbursement Manual Section 2203)
- Charges must constitute reimbursable benefits under the applicable plan
- Charges comply with Billing Guidelines, Uniform Billing Editor, and CMS Provider Reimbursement Manual; billed acuity level (revenue code) must match resource consumption thresholds specified in the Uniform Billing Editor
Key error/discrepancy categories
- Billing errors (duplicate billing, data entry errors, excessive pharmaceutical/implant markups, inappropriate intervals, components of primary procedure billed separately, excessive therapy units)
- Experimental/Investigational (non-reimbursable drugs or treatments)
- Incorrect bill type submitted
- Incorrect charges (price or quantity discrepancies)
- Insufficient description to evaluate the charge
- Level of care not supported by patient acuity
- Non-covered services under the health plan
- Services not authorized when authorization is required
- Quality of care issues (never events, hospital-acquired conditions)
- Unbundling (routine supplies/services billed separately when included in room & board or integral to another procedure)
Payment & appeals
- Company pays the clean portion of the claim per the clean claim review recommendation within timely payment requirements
- Provider may appeal; responses to appeals provided as necessary and Company will support findings during resolution
Roles & responsibilities
- Payment Integrity manages vendors who conduct clean claim reviews
- Claims Operations processes payment adjustments based on review findings and referrals
Billing, Codes, and Thresholds
| References compliance with CMS billing standards, Uniform Billing Editor, and CMS Provider Reimbursement Manual Section 2203 regarding relationship of billed charges to costs. |
Referral & Provider Response Process
Clean claim review referral and provider response process
Claims that meet established referral criteria are referred for clean claim review using the itemized bill; the Company will review all hospital claims against these criteria to determine eligibility. Triggers include pre‑ or post‑payment inpatient claims with payable charges greater than $25,000, inpatient claims that hit a DRG outlier or percent of billed charges, and any other concerning claims. A Claim Review Report listing exceptions is sent to the provider/facility; the Company pays the clean portion per the review recommendation within timely payment requirements. Providers must respond to exceptions and appeals and may clear unpaid charges by submitting medical records, invoices, doctor orders, provider contracts, billing policies, or other clinical information during the resolution process. If documentation clears exceptions, the previously unpaid or recovered charges will be paid to the provider at that time.
- Referral triggers: Inpatient claims > $25,000 payable charges; DRG outliers or % of billed charges; other concerning claims. [[source]]
- Review process: Clean claim reviews performed using the itemized bill; Claim Review Report with exceptions is sent to provider/facility. [[source]]
- Timelines & payment: Company pays the clean portion per the clean claim review recommendation within timely payment requirements. [[source]]
- Provider response: Providers must submit supporting documentation (medical records, invoices, orders, provider contracts, billing policies, or other clinical information) to clear exceptions during appeals or resolution. [[source]]
Key Terms
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