Billing
Clean Claims Checklist
Submit claims that get paid the first time with this comprehensive checklist.
A "clean claim" is one that's complete, accurate, and meets all payer requirements. Clean claims get paid faster with fewer denials. Use this checklist before every claim submission.
Member Information
Member name matches Medicaid enrollment exactly
Member ID/Medicaid number is correct
Date of birth matches member record
Member was eligible on date of service (verified)
Correct payer identified (FFS vs. MCO)
Provider Information
Billing provider NPI is correct
Rendering provider NPI (if different)
Provider enrolled with this payer
Tax ID matches enrollment
Service address is correct
Authorization
Prior authorization obtained (if required)
Authorization number included on claim
Service date falls within authorization dates
Units billed don't exceed authorized units
Service matches what was authorized
Service Information
Date(s) of service are accurate
Place of service code is correct
Procedure code is valid and active
Modifier(s) applied correctly (if needed)
Units calculated correctly from documentation
Diagnosis code supports medical necessity
Documentation Support
Service is documented in the record
Documentation supports units billed
EVV record matches claim (if applicable)
Notes are signed and dated
Documentation available if audited
Claim Integrity
Not a duplicate of previous submission
Within timely filing deadline
Charge amount is correct
All required fields populated
Claim format meets payer requirements
Common Reasons Claims Aren't Clean
- Member eligibility not verified before service
- Wrong payer billed (FFS vs. MCO)
- Authorization expired or wrong auth number
- Typos in member ID or provider NPI
- Procedure code changed but claim template not updated
- Units calculated incorrectly from documentation
- Duplicate claim submitted accidentally
Building a Clean Claim Process
- Verify eligibility routinely (daily or per-service)
- Ensure authorizations are in place before service
- Use claim scrubbing software to catch errors
- Train staff on documentation requirements
- Review claims before batch submission
- Monitor clean claim rate and investigate issues
Submit Clean Claims Every Time
One Care Portal scrubs claims before submission, catching errors that cause denials. Build claims from verified documentation and authorized services.
Learn about our billing software