14.10 Clean Claims Payment :: IntegraNet Health

New Claims System Update

Provider Manual

14 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES

14.10 Clean Claims Payment

A clean claim is a request for payment for a service rendered by a provider that:

Is submitted in a timely manner.

Is accurate to include all required information and supporting documentation.

Is submitted on a HIPAA-compliant standard claim form, including a CMS-1500 or CMS 1450 or successor forms thereto or the electronic equivalent of such claim form.

Requires no further information, adjustment or alteration by the provider or by a third party in order to be processed and paid by IntegraNet.

Clean claims are typically adjudicated within 30 calendar days of receipt. If IntegraNet does not adjudicate the clean claim within the time frames specified above, IntegraNet will pay all applicable interest as required by law.

IntegraNet produces and mails an EOP on bi-weekly basis, which delineates for the provider the status of each claim that has been adjudicated during the previous payment cycle. Upon receipt of the requested information from the provider, IntegraNet should complete processing of the clean claim within 30 calendar days.

Paper claims determined to be unclean will be returned to the billing provider along with a letter stating the reason for the rejection. Electronic claims determined to be unclean will be returned to the IntegraNet contracted clearinghouse that submitted the claim.

In accordance with CMS requirements, IntegraNet will pay at least 95 percent of all clean claims from practitioners either in individual or group practice or who practice in shared health facilities within 30 calendar days of the date of receipt. IntegraNet will pay or deny all other claims within 60 calendar days of the receipt of the request. The date of receipt is the date IntegraNet 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.