Clean Claims And Rejections (Upfront Rejections vs. Denials)
Clean Claims are a type of a claim that does not require external investigation or development to obtain information not available on the claim form or on record in the health plan’s systems in order to adjudicate the claim. Clean claims must be filed within the timely filing period. Any claim that does not meet the definition of a clean claim is considered a non-clean claim. Nonclean claims typically require external investigation or development in order to obtain all information necessary to adjudicate the claim.
An upfront rejection is defined as an unclean claim that contains invalid or missing data elements required for acceptance of the claim into the claim processing system. Upfront rejections will not enter Buckeye Health Plan claims adjudication system, so there will be no Explanation of Payment (EOP) for these claims. The provider will receive a letter or a rejection report if the claim was submitted electronically. If all edits pass and the claim is accepted, it will then be entered into the system for processing. A DENIAL is defined as a claim that has passed edits and is entered into the system, however has been billed with invalid or inappropriate information causing the claim to deny. An EOP will be sent that includes the denial reason.
Participating providers must submit first time claims within 12 months or one calendar year of the date of service. Claims received outside of this timeframe will be denied for untimely submission. All corrected claims, requests for reconsideration or claim disputes from participating providers must be received within 180 days from the date of explanation of payment or denial is issued. All providers who have rendered services for Buckeye Health Plan Medicare Advantage members can file claims. It is important that providers ensure Buckeye Health Plan Medicare Advantage has accurate and complete information on file.