Clean Claims

Clean Claims, Unclean Claims, Rejected Claims And Claims Resubmission (Midwest Health Plan)

Clean Claims are claims that have all information in them and nothing is missing. If any mandatory or conditional information is missing, the claim will be considered unclean. Examples of unclean claims include invalid member ID, provider data discrepancy NPI and atax ID does not match.

HAP Midwest Health Plan pays clean claims and/or denies defective claims within 45 days. Providers are highly encouraged to status any claims that they have submitted but not received payment or denial after 45 days from submission date.

Unclean claims are considered “defective” and will be returned or rejected with in 45 days. Office of Finance and Regulations (OFIR) requires HAP Midwest Health Plan to report all defective claims on quarterly basis.

Claims are returned when Midwest Health Plan is not able to enter them in the system due to invalid information – they are not clean claims (e.g. billing provider not on system, member not enrolled in HAP Midwest Health Plan). These claims cannot be tracked hence cannot be statused. This makes it very important for the provider to resubmit those claims appropriately within the filing time limits.

Claims are rejected when enough information is available to enter the claim in the system, yet other pertinent information needed to complete the reimbursement process is missing. Rejections are stored in the system hence, these claims can be statused. Midwest Health Plan highly encourages your staff to work these rejections and resubmit with corrections in a timely fashion.

Claim correction and resubmission

If all service lines of a claim are rejected and the provider determines that the information can be corrected, the services must be resubmitted as a new claim with the correct information. Facility and professional bills may be submitted as new claims.

Examples of claim adjustment that are submitted when:

  • all or a portion of the claim was under/over paid, or
  • services are added or deleted to the original submission, or
  • a third party payment was received after HAP Midwest Health Plan made payment.

It is very important to include all service lines from the original claim not just adjusted line or late charge adjustment. When an adjustment claim is received, HAP Midwest Health Plan will reverse the original claim and reenter the newly billed claims to assure total readjudication and correct payment.
Do not submit a claim as an adjustment claim when there has been no payment issued by HAP Midwest Health Plan on a previous claim.

How to Submit a Replacement/Adjustment Claim

When resubmitting a previously processed claim, you must indicate the resubmission via proper coding. On the UB-04 use bill type XX7 or XX 8, FL- 64 must contain the original form # from HAP Midwest Health Plan Remittance advice and the Remarks Section MUST reference the reason for claim adjustment in brief.

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