How to Improve Clean Claim Rate

The Clean Claim Rate on the Home Dashboard quickly indicates the organization's success at claims being accepted by the payer on the first pass. Anything less than 100% is an opportunity to review billing practices and policies to identify issues that could lead to delayed payment or reduced reimbursements.  Those issues might include incorrect coding and changing payer requirements. 

This tile displays the percentage of claims that pass through clearinghouse edits and are accepted by the payer on initial claim submission (1.1 claims) without any rejections.  

The calculation is (100 - (total rejected 1.1 claims / total number of 1.1 claims)) for the date range selected. 

Locating Resubmitted Claims

The Claim Submission Report can show you an option for "only resubmitted claims" which will show all claims that had to be resubmitted at least once because of some correction added to the claim.

Any claim that only has a 1.1 instance and has had no corrections is considered a clean claim. Any claim that has had a 1.2 or 1.3, etc, would not be considered a clean claim. (See the "Version" column for the instance number.)

Reviewing Issue Tags

Pair this with the Issues that are tagged to your claims to see what reasons claims were resubmitted. View the issues tagged to a claim with the Claim Status Report (By Claim) by adding the Claim Issues column.

If you're not seeing the level of detail that you want in the claim issues column of that report, update the issue tags in Managing Org Admin > Configuration > Claim Issues Types and ask the rest of the team to start adding appropriate issues when resubmitting claims. See more information on creating issue tags in The Avea Way: Best Practices for Configuration.