Understanding Clean Claims, Corrected Claims, and Duplicate

Claims in US Healthcare

Introduction

Claims processing is a critical component of the US healthcare system, ensuring that healthcare
providers receive timely reimbursement for services rendered to patients. A smooth claim
adjudication process depends on the accuracy and completeness of the submitted claims.
However, claim submission errors, missing information, and duplicate submissions can cause
delays, rejections, and financial loss for providers.

To maintain efficiency and compliance, it is essential to understand the different types of

claims:

• Clean Claims – Claims that are error-free and can be processed without manual
intervention.
• Corrected Claims – Claims that have been resubmitted with necessary corrections to
fix errors in the original submission.
• Duplicate Claims – Claims submitted more than once for the same service, patient,
and provider, often leading to denials or delayed payments.

This document explains how each type of claim is recognized in both paper and EDI 837
formats and the best practices providers and payers can follow to ensure claims are adjudicated
on time.

1. Clean Claims

A clean claim is one that contains all required information, is free from errors, and meets the
payer's guidelines for processing. These claims can be adjudicated without requiring manual
intervention, leading to faster reimbursements.

How Clean Claims are Recognized?

• Paper Format: Claims submitted via CMS-1500 (Professional Claims) or UB-

04 (Institutional Claims) must be legible, complete, and free from any missing or
incorrect details.
• EDI 837 Format: Electronic claims sent through EDI 837P (Professional)
or 837I (Institutional) must comply with the HIPAA-mandated format, meet payer-
specific validation checks, and pass syntax and segment validations.

Common Errors Preventing Clean Claims

• Patient demographic errors (e.g., incorrect date of birth, name mismatch).

• Invalid insurance information (e.g., incorrect payer ID, expired coverage).

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 • Coding mistakes (e.g., invalid CPT, HCPCS, or ICD-10 codes).
• Missing prior authorization or referrals.
• Incorrect provider details, including missing NPI (National Provider Identifier).
• Claims submitted after the filing deadline.

Additional Tips for Ensuring Clean Claims

• Use claim scrubbing software to identify and correct errors before submission.
• Conduct regular staff training on coding updates and payer-specific requirements.
• Maintain a checklist of required fields for each claim type (e.g., CMS-1500 or UB-
04).

By ensuring that all claims meet these criteria before submission, providers can significantly
reduce denials and processing delays.

2. Corrected Claims

A corrected claim is a claim that has been resubmitted to fix errors from the original claim
submission. Providers must clearly indicate that the claim is a correction rather than a
duplicate submission.

How Corrected Claims are Recognized?

• Paper Format: A corrected claim is marked as "Corrected Claim" with the original
claim reference number noted.
• EDI 837 Format:
o Loop 2300 CLM05-3 must indicate that the claim is corrected.
o REF segment (Original Reference Number) must contain the previously
submitted claim number.
o Claim Frequency Code in CLM05-3:
▪ "7" = Corrected Claim.
▪ "8" = Void/Delete Claim.

Common Scenarios for Corrected Claims

• Incorrect CPT, HCPCS, or ICD-10 code.

• Incorrect billed amount or modifier usage.
• Missing or incorrect place of service (POS) code.
• Updating provider details (e.g., NPI corrections).

Additional Tips for Corrected Claims

• Always include a cover letter or explanation when submitting corrected claims via
paper.

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 • Use the EDI 277 Claim Status Response to identify errors in the original claim
before resubmitting.
• Ensure corrected claims are submitted within the payer’s specified timeframe (e.g., 90
days from the date of service).

Timely and correctly resubmitting corrected claims prevents unnecessary denials and
improves revenue cycle efficiency.

3. Duplicate Claims

A duplicate claim occurs when a provider submits the same claim multiple times for the
same service, provider, and patient, often leading to denials or processing delays.

How Duplicate Claims are Recognized?

• Paper Format: Manual review or Optical Character Recognition (OCR) software

detects repeated claim submissions.
• EDI 837 Format:
o Payers use Claim Control Numbers (CCN) to identify duplicate
submissions.
o Claim matching algorithms compare patient ID, provider NPI, date of
service, and billed amount to detect duplicate claims.

Common Causes of Duplicate Claims

• Resubmitting a claim without checking its status.

• Submitting the same claim electronically (EDI) and via paper.
• System-generated duplicate submissions due to EHR errors.

Additional Tips to Avoid Duplicate Claims

• Implement a claim tracking system to monitor the status of submitted claims.

• Use EDI 276/277 transactions to check claim status before resubmitting.
• Train staff to avoid manual errors that lead to duplicate submissions.

Avoiding duplicate claims helps providers reduce claim denials and unnecessary
administrative burden.

4. Measures to Ensure Timely Claim Adjudication

To improve claim adjudication times and ensure timely payments, both providers and payers
must adopt best practices for claim submission and processing.

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 For Providers:

• Use Claim Scrubbing Tools: Automated pre-submission validation tools detect

errors before claims are sent.
• Verify Patient Eligibility & Benefits: Use EDI 270/271 transactions to confirm
active coverage.
• Ensure Proper Coding Compliance: Follow ICD-10, CPT, and HCPCS guidelines.
• Submit Claims Electronically (EDI 837): Reduces manual errors and processing
time.
• Monitor Claim Status (EDI 276/277): Regularly check claim processing updates.
• Avoid Duplicate Submissions: Wait for payer response before resubmitting.
• Include Necessary Attachments: Provide supporting documentation (e.g., medical
records, referrals).

For Payers:

• Implement Auto-Adjudication Rules: Optimize business rules engines to auto-

process clean claims.
• Detect Duplicate Claims Early: Use AI-based detection systems for claim
validation.
• Timely Communication with Providers: Send EDI 277 claim status reports to
resolve issues promptly.
• Ensure Compliance with Federal Timelines: Process claims within prompt pay
laws (e.g., 30 days for clean claims).
• Leverage AI and Analytics: Identify patterns in claim denials and address them
proactively.

Conclusion

Efficient claim submission and processing are crucial for a well-functioning healthcare revenue
cycle. Clean claims ensure faster reimbursements, corrected claims help resolve billing errors,
and duplicate claims should be avoided to prevent denials. By adopting best practices such as
automated claim validation, eligibility verification, and proactive communication, both
providers and payers can streamline the claims adjudication process.

Understanding these concepts and implementing the right strategies will reduce claim
rejections, enhance revenue cycle efficiency, and ultimately lead to better financial outcomes
for healthcare organizations.

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