New York Regulators Clarify The Definition Of Clean Claim

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New York state insurance regulators are trying to keep disputes about the definition of “clean claim” from further damaging relations between health carriers and health care providers.

Gregory Serio, the states insurance superintendent, has adopted an emergency regulation, Regulation 178, that lists exactly which fields providers and patients must complete when filling out 2 popular claim forms, the CMS 1500 form and the HCFA 1450 form.

The essential fields ask for information about matters such as the name of the patient, the patients address, the patients birth date, the place of service, the diagnosis code and whether the patients medical problem is the result of an automobile accident.

Serio says he is adopting the emergency regulation, in part, because his states health carriers have asked for a clear-cut clean-claim definition.

The new definition “will prevent providers from submitting unnecessary complaints to the Insurance Department regarding claims that are deficient,” Serio says in statement explaining why he has adopted the definition regulation on an emergency basis.

New York is basing its definition on a definition used in Connecticut, and the American Medical Association, Chicago, says the clean-claim definition issue continues to cause headaches in many states.

In the late 1990s, health insurance agents and employers watched in frustration as doctors and hospitals fought with health carriers over what providers argued were unreasonable payment delays. Many doctors and large group medical practices left carriers because of concerns about payment delays and other payment issues. The turmoil hurt agents who wanted to be able to tell customers which providers would be in a plans network.

In some cases, carriers complained, providers were blaming the carriers for problems that were the result of inaccurate, incomplete claim forms.

Since then, more than 40 states have enacted laws that require carriers to pay clean claims promptly. Although the prompt-pay laws have helped speed up payments, only one-third of the prompt-pay states have clean-claim definitions, and ambiguity about the term continues to lead to problems, the AMA says.

The Star-Telegram, a newspaper in Fort Worth, Texas, reported an anecdote in May 2003 about a surgeon who said a carrier treated a claim as non-clean because he had forgotten to put a period at the end of a sentence.

Medicare, the federal program for U.S. residents who are disabled or are over age 65, defines a clean claim as a “claim that has no defect or impropriety, including lack of required substantiating documentationor particular circumstances requiring special treatment that prevents timely payment and that otherwise conforms to the clean-claim requirements for equivalent claims under original Medicare”

Experts note that the Medicare definition does not say which claim form fields providers must fill out, and even the New York definition leaves some room for judgment. It lets providers leave fields that are not applicable to a particular patient blank.

In Texas, a state where an old prompt-payment law governs some provider contracts and a new prompt-payment law governs others, the Texas Department of Insurance has headed off clean-claim definition problems by setting up a claims-processing technical advisory committee and organizing an aggressive education campaign, according to Audrey Selden, the Texas departments senior associate commissioner for consumer protection.

Like Connecticut and New York, Texas has guides that tell providers exactly which claim form fields they must fill out.

“We still do receive complaints from physicians,” Selden says.

But the volume of complaints that involve questions about the clean-claim definitions and related payment issues seems to be lower than it used to be, Selden says.


Reproduced from National Underwriter Edition, August 5, 2004. Copyright 2004 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.