EDI Clean Claim

EDI Clean Claim Definition And Guides

A clean claim is defined as a claim received by Louisiana Healthcare Connections for adjudication, in a nationally accepted format in compliance with standard coding guidelines, and which requires no further information, adjustment or alteration by the provider of services in order to be processed by Louisiana Healthcare Connections.

The following exceptions apply to this definition:

  • A claim for which fraud is suspected
  • A claim for which a Third Party Resource should be responsible

It is the provider’s responsibility to check their audit report to verify that Louisiana Healthcare Connections has accepted their electronically submitted claim.

Clean claims will be adjudicated (finalized as paid or denied) within 15 business days of the receipt of the claim. Non-clean claims will be adjudicated (finalized as paid or denied) within 30 days of receipt of the electronic claim. Claims pended for additional information must be closed (paid or denied) by the 30th calendar day following the date the claim is pended if all requested information is not received prior to the expiration of the 30-day period.

Louisiana Healthcare Connections will send providers written notification via the web or an Explanation of Benefits (EOB) for each claim denied, including the reason(s) for the denial, the date contractor received the claim and a reiteration of the outstanding information required from the provider to adjudicate the claim.

To learn more about EDI and become a certified EDI Professional, please visit our course schedule page.

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