Clean Claim Rate

What is a Clean Claim?

A clean claim is a claim that contains all required information for payer processing and that the payer can adjudicate (pay, partially pay, or deny based on coverage) on the first submission without requesting additional information or returning the claim. CMS defines a clean claim as one that has no defect or impropriety and can be processed and paid without requesting additional information from the provider or submitter. Under the Prompt Payment Act, Medicare is required to pay clean claims within 14 days of electronic submission.

Industry Benchmark and Financial Impact

The industry benchmark for clean claim rate is 95% or higher. High-performing billing operations achieve 97–99%. The financial impact of a sub-benchmark clean claim rate is significant:

• Rework cost: Correcting and resubmitting a denied claim costs an average of $25–$118 per claim in staff time, depending on denial complexity
• Cash flow impact: Each rejected or denied claim adds 30–60+ days to the collection cycle
• Write-off risk: Claims that miss timely filing deadlines or are denied and not worked become permanent write-offs

For a practice generating 10,000 claims/year, moving from 90% to 95% clean claim rate prevents 500 denials/rejections annually — saving approximately $12,500–$59,000 in rework costs alone, plus accelerating $40,000–$80,000 in cash flow.

Edits vs Denials: An Important Distinction

Clean claim rate is affected by both claim edits (returned before payer receipt for correction) and denials (received by payer but refused for payment). Front-end edits — caught by the practice management system before submission — are less costly to address than back-end denials, which have already been sent to and refused by the payer. Best-practice revenue cycle operations focus on maximising front-end edit prevention through eligibility verification, clinical documentation review, and pre-submission claim scrubbing.

Root Causes of Low Clean Claim Rate

Common root causes include: incomplete or inaccurate patient demographic/insurance data at registration (leading to eligibility denials), missing or incorrect prior authorisation (PA denials), documentation insufficient to support billed diagnosis or procedure codes (medical necessity denials), incorrect code combinations (modifier errors, bundling violations), and lack of NPI or taxonomy code maintenance. Tracking clean claim rate by provider, payer, and denial reason code points to specific, actionable improvements.