CMS Pub. 100-04, ch. 1, § 80.2

HO-401.D, A3-3600.1, B2-5240.11.A

A “clean” claim is one that does not require the carrier or FI to investigate or develop

external to their Medicare operation on a prepayment basis. Clean claims must be filed in

the timely filing period.

The following bullets are some examples of what are considered clean claims:

• Pass all edits (contractor and Common Working File (CWF)) and are processed

electronically);

• Not require external development (i.e., are investigated within the claims, medical

review, or payment office without the need to contact the provider, the

beneficiary, or other outside source) (Note: these claims are not included in CPE

scoring).

• Claims not approved for payment by CWF within 7 days of the FI’s original claim

submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF

system/communication difficulties);

• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is

not on the CWF host and CWF has to locate and identify where the beneficiary

record resides;

• Claims subject to medical review but complete medical evidence is attached by

the provider or forwarded simultaneously with EMC records in accordance with

the carrier’s or FI’s instructions;

• Are developed on a postpayment basis; and,

• Have all basic information necessary to adjudicate the claim, and all required

supporting documentation

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