A clean claim is a claim submitted correctly the first time.
Clean claims are paid 80-90% of the time on first submission. Dirty claims (incorrect information, missing data, wrong codes) get denied, require resubmission, and delay payment 30-60 days.
What Makes a Claim Clean
Correct patient information: DOB, SSN, member ID all match insurance records exactly.
Correct provider information: Your NPI, license number, office address all correct.
Correct treatment codes: CDT codes match what you actually provided (not what you hoped to provide).
Correct billing amount: Your fee for the treatment matches what you submitted.
Coordination of benefits: If secondary insurance, COB is correct.
Pre-authorization: If required, pre-auth number is included.
Medical necessity documentation: If applicable, clinical notes or radiographs support the treatment.
Timely filing: Claim is submitted within 30 days of treatment (or within the plan’s time limit).
The Clean Claim Checklist
Before submission:
- [ ] Patient eligibility verified
- [ ] Insurance information current and accurate
- [ ] Pre-auth obtained (if required) and number noted
- [ ] Treatment codes verified for accuracy
- [ ] Billing amount matches your fee schedule
- [ ] Medical necessity documented
- [ ] Claim is complete (no missing fields)
- [ ] Claim will be submitted within 30 days of treatment
Common Claim Errors
Wrong treatment code: You performed a crown. You coded it as a filling. Deny. Resubmit.
Patient DOB wrong: Insurance cannot match patient. Deny. Resubmit with correct DOB.
Missing pre-auth number: Treatment required pre-auth. You forgot to include it. Deny. Resubmit.
Billing amount does not match: Your fee is $1,200. You billed $1,000. Insurance pays $1,000 (80% = $800). You expected $960. Patient is confused.
Deductible not applied: Claim submitted. Deductible was not met. You should have collected it from patient. Now there is a dispute.
Timely filing violation: You submit claim 90 days after treatment. Insurance denies due to timely filing. Claim cannot be resubmitted.
Automation Helps
Your PMS (Dentrix, EagleSoft, OpenDental, Curve) should have claim submission built in. It auto-populates patient and provider information, verifies codes, checks timely filing, and flags missing pre-auth.
But someone still has to review before submission. Reach team members trained in clean claims do this review.
Reach Ensures Clean Claims
Your remote team member:
- Verifies all patient information
- Confirms codes are correct
- Notes pre-auth numbers
- Reviews billing amounts
- Checks timely filing
- Submits via your PMS
- Tracks submission status
- Follows up on denials
Result: 95%+ clean claim rate. Fast payment. Fewer denials.
Performance Metrics
Clean claim rate: % of claims paid without issue on first submission
Target: 90%+
Denial rate: % of claims denied
Target: 5% or less
Days to payment: How long from claim submission to payment received
Target: 15-20 days
FAQ
**Q: What percentage of claims should be clean?**
A: Industry standard is 85-90%. Best practices achieve 95%+.
**Q: Can I automate clean claim submission?**
A: Partially. Your PMS automates data entry. Someone still reviews before submission.
**Q: How do I track clean claim rate?**
A: Your PMS or billing software reports this. Request monthly clean claim reports.
**Q: What if my clean claim rate is low?**
A: Audit denials. Find the pattern. Fix the process. Train staff.
**Q: How much does clean claim rate affect DSO?**
A: Significantly. Dirty claims get denied and resubmitted, adding 30-60 days to collection.