What can lead to a claim being categorized as “clean”?

A claim is categorized as “clean” when it is submitted with complete and accurate patient and service information. This designation indicates that the claim includes all necessary details, such as the patient's demographic information, valid diagnosis codes, specific procedure or service codes, and any relevant prior authorizations. When all these components are present and correct, it helps facilitate a smoother and quicker approval process by the payer, reducing the chances of delays or denials.

In the context of pharmacy billing, a clean claim is essential for ensuring that reimbursement is received promptly and that the workflow remains efficient for both pharmacy and payer. Clean claims are critical in maintaining the financial health of a pharmacy, as they help minimize the administrative burden associated with claim corrections, resubmissions, and appeals.