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Regulation and Compliance > State Regulation

New York Tries To Clarify Clean-Claim Definition

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New York state insurance regulators are trying to give doctors, hospitals and health carriers a clearer definition of what constitutes a clean claim.[@@]

The regulators have adopted an emergency regulation that lists what information providers and their patients must provide when filling out 2 popular standard claim forms.

The regulation, Regulation 178, lists the essential fields on the CMS 1500 claim form and the HCFA 1450 claim form. The essential fields include the fields that ask about matters such as the patient’s name, address, birth date, place of service and diagnosis code.

New York lawmakers enacted a health claim prompt-payment law back in 1997. The law requires carriers to pay “clean claims” quickly, unless insurers have reasons to suspect fraud or have some other good reasons to ask for more information.

Since 1997, the New York Insurance Department has received more than 88,000 complaints from doctors, hospitals and other providers about slow health carrier payments, and many involved questions about whether claims were clean claims, according to state Insurance Superintendent Gregory Serio.

The New York department has organized a forum to give carriers and providers a chance to discuss clean-claim standards. But creating an emergency definition in Regulation 178 “will prevent providers from submitting unnecessary complaints to the Insurance Department regarding claims that are deficient,” Serio writes in a document that explains the need for adopting Regulation 178 as an emergency measure.

But Regulation 178 leaves some room for interpretation, because it notes that providers can leave information out when fields are “not relevant in a particular instance.”

The New York department has posted the emergency regulation on the Web at