Highmark Clean Claim Guidelines For Providers
Highmark Clean Claim is defined as a claim with no defect or impropriety and one that includes all the substantiating documentation required to process the claim in a timely manner. The core data required on a claim to make it clean are outlined in this section and the next section. Unclean claims are those claims where an investigation takes place outside of the corporation to verify or find missing core data. An example of this is when a request is sent to the member for information regarding coordination of benefits. This may require obtaining a copy of an Explanation of Benefits (EOB) from the member’s other carrier. Claims are also considered unclean if a request is made to the health care professional for medical records. Claim investigations can delay the processing of the claim.
You must provide Highmark with the required information in order for the claim to be eligible for consideration as a “clean claim.” If changes are made to the required data elements, this information shall be provided to network providers at least thirty (30) days before the effective date of the changes.
A description of the data elements necessary to ensure that facility claims are without “defect or impropriety” can be found in the current Official UB-04 Data Specifications Manual. This manual is available from the National Uniform Billing Committee (NUBC). For professional services, please see the current 1500 Health Insurance Claim Form Reference Instruction Manual from the National Uniform Claim Committee (NUCC).