Clean Claim

A clean Medicare home health claim carries a supported HIPPS code consistent with the OASIS assessment, a timely Notice of Admission (NOA) on file, correct dates and visit data for the 30-day period, valid patient and provider identifiers, and proper claim sequencing, since Medicare requires home health periods to be billed in order. For Medicare Advantage and managed care, clean also means the authorization number is present and matches the services billed, and the claim reaches the payer within timely filing limits. Behind the claim itself sits the eligibility file: signed plan of care, face-to-face documentation, and orders, which keep a paid claim clean when it is reviewed later.

Every claim that fails first-pass adjudication costs the agency twice. First in time: a rejected or held claim adds days or weeks to payment, stretching Days Sales Outstanding (DSO) and forcing the agency to fund payroll from reserves or a credit line. Second in labor: reworking a claim consumes real staff hours, and industry estimates consistently put rework cost at many times the cost of submitting correctly the first time. Because home health bills in 30-day periods under sequential billing rules, a single dirty claim can also dam up the periods behind it, multiplying the cash impact. Agencies with clean claim rates in the high 90s run leaner billing teams and steadier cash than agencies constantly firefighting rejections.

Clean claims are manufactured upstream, not scrubbed into existence at billing:

• Verify eligibility and payer at referral and again at start of care, including Medicare Advantage enrollment
• Submit the NOA within 5 calendar days of the start of care
• Secure authorizations before or immediately after admission for managed care patients
• Reconcile visits, orders, and documentation before claim creation, not after rejection
• Use claim scrubbing edits tuned to home health: HIPPS, sequencing, and payer-specific rules
• Track rejection reasons weekly and fix the top recurring defect each month

Each fix compounds: most dirty claims trace back to a handful of repeatable intake and documentation defects.

A claim can sail through adjudication and still be a liability. First-pass payment proves the data on the claim was internally consistent; it does not prove the underlying episode meets Medicare coverage rules. Postpayment reviewers, from Medicare Administrative Contractors to Unified Program Integrity Contractors, judge the medical record, not the claim form. The standard worth aiming for is a claim that is both clean and defensible: it pays on first pass, and if records are requested a year later, the face-to-face documentation, homebound support, skilled need evidence, and signed orders are already complete in the chart. Agencies that build QA review into the pre-billing workflow get both properties from the same process.