Clean Claim

A clean claim is one that passes every payer edit on first submission and is adjudicated without additional information requests, denials, or rejections. Industry average for clean claim rate is 85-90%. Top-quartile practices and specialized billing teams hit 96%+ clean claim rates. The difference is direct dollars: a clean claim costs roughly $3 to process, while a denied claim costs $25-118 to rework according to CAQH and MGMA data — and 65% of denied claims are never resubmitted at all because the labor cost exceeds the claim value. A 10-percentage-point improvement in clean claim rate on a practice billing $1.5M annually recovers $30-80K in margin per year through reduced rework labor alone, before counting the additional revenue from claims that previously aged into write-off territory. Clean claim rates depend on three foundations: real-time eligibility verification 48-72 hours before service (kills CO-4 and PR-1 denials), payer-specific clean-claim scrubbing rules that catch missing NPIs, taxonomy codes, NDCs, CLIA numbers, and place-of-service codes (kills CO-16 denials), and AAPC-certified coding with NCCI edit checks before submission (kills CO-97 bundling denials). Practices that hit 96%+ clean claim rates do all three systematically — practices stuck below 90% typically have a gap in one of the three.