Medical billing clean claim definition

The following definition shall apply to clean claims as used within the Horizon NJ Health Billing Guide:

“Clean claim means one that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.”

Under the New Jersey Health Claims Authorization, Processing and Payment Act, claims must also meet the following criteria:

(a) the health care provider is eligible at the date of service;
(b) the person who received the health care service was covered on the date of service;
(c) the claim is for a service or supply covered under the health benefits plan;
(d) the claim is submitted with all the information requested by the payor on the claim form or in other instructions that were distributed in advance to the health care provider or covered person in accordance with the provisions of section 4 of P.L.2005, c.352 (C.17B:30-51); and
(e) the payor has no reason to believe that the claim has been submitted fraudulently. Other requirements, including timeliness of claims processing shall mean:Horizon NJ Health must receive all claims within 180 calendar days from the initial date when services were rendered. If claims are not received within 180 calendar days from initial the date of service, claims will be denied for untimely filing. Horizon NJ Health shall pay all clean claims from hospitals, physicians and other health care professionals within 30 days of the date of receipt of EDI claims and within 40 days for paper claims.

The time limitation does not apply to claims from providers under investigation for fraud or abuse.
The date of receipt is the date Horizon NJ Health receives the claim, as indicated by its date stamp on the claim.
The date of payment is the date of the check or other form of payment.

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