New York Regulators Clarify The Definition Of Clean Claim
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.