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Essential Claim Submission Guidelines to Maximize Revenue

Claim submission guidelines are vital if your healthcare practice’s clean claim rate is below 95%. Anything less than the 95% clean claims rate means your medical practice is losing revenue with increased expenses owing to claim rejections. It is telling for your practice that the first submission determines the percentage of the clean claim rate. Strategic medical billing services help maintain a clean claim rate for a profitable healthcare practice. Following guidelines can result in a 95% clean claim rate, that is after careful examination of the healthcare practice. 

Following are some strategies and tips to improve the clean claim rate and your practice revenue cycle.

Ways to Achieve Maximum Revenue and Enhance Clean Claim Submission

Your practice will achieve higher revenue by indulging in the proactive claim submission guidelines. A few simple and easy steps of claim entrance facilitate your medical staff in obtaining the highest patient collections. Efficient medical billing services help your healthcare practice stay up-to-date with the prevailing healthcare guidelines. Your practice can easily overcome the barriers that arise during the payment possession. This is achievable by following the helpful claim submission guidelines given below.

1. Keep the patient information updated:

A medical claim contains all the information regarding a patient’s visit to the healthcare provider. Claims come with all-inclusive information of the patient, whether it’s personal, medical, or insurance. Moreover, the medical claims also cover the information related to the provider and insurer(s). Your patient’s information may require subtle changes and updates as time passes. If your staff doesn’t focus on updating outdated patient information, it will become outdated or invalid. Most claim denials or rejections happen due to a lack of claim review systems. To avoid delays, updating the info requires confirming the patient’s details before appointment. In actionable claim submission guidelines, it is mandatory to use precise documentation. Correct documentation plays a crucial role in proper medical billing processes.

2. Pre-Eligibility Assessment

Two types of patients are part of every healthcare practice, either by being established patients or new patients. If your medical staff doesn’t pre-analyze the insurance information of every patient, it results in lesser clean claims. Your medical practice can reduce claim denials by assessing the pre-eligibility criterion of every patient as part of its claim submission guidelines. A provider must check the insurance information of new and established patients to identify any changes. To reach the 95% clean claim rate, your medical staff needs to assess three levels of insurance information (primary, secondary, and tertiary). All of this includes patients’ co-payments, out-of-the-network benefits, and deductibles.

3. Well-Organized Patient Documentation

Detailed Documentation is another aspect of claim submission guidelines that ensures a higher clean claim rate. The details of service deliverables, medical and case history, or any other information required as part of proper patient documentation. Well-organized patient records are essential in the medical billing process. The accuracy of the data matters due to its direct impact on coding. Incorrect Documentation leads to wrong codes, which result in claim denials and rejections.

4. Stay Updated with the Payer's Timeline

Another important aspect of claim submission guidelines is assessing the payer’s guidelines on time. Every practice staff needs to stay up-to-date with the changing payer’s guidelines. This also includes whether your payers accept electronic or paper-based medical claims. If your medical team is not following the requirements of the insurance payers, it will result in claim denials and rejections. When your medical staff monitors the submission deadlines, you can achieve a higher clean claim ratio. This will resolve maximum discrepancies in patient coverage to avoid the cause of denials.

5. Ensure Error-Free Claims:

Errors in medical claims can occur because of human error and the use of incorrect, outdated patient information. These errors result in denials or rejections of medical claims, leading to a lesser clean claim rate. Submitting error-free claims in the first go is necessary to sustain a high clean claim rate.

6. Quality Checkpoints Before Claim Submission

Quality checks are essential as a final step before claims submission. Your medical staff must access several things, such as patient demographics and other important details. To improve the rate of clean claims, it is important to analyze the errors in each claim before submissions.


Several things are part of an error-free claim submission process. Minimum errors will lead to the least claim denials and maximum revenue. Like, every bit of payment you deserve to receive, it is important to update the patient’s information and make it error-free. Claim submission guidelines incorporate a proactive approach to solve maximum errors before final submission. Your practice can manage patient care besides acquiring maximum reimbursements by staying updated about the payer’s requirements. 

Frequently Asked Questions

Some insurance companies may have specific formatting requirements, such as using a particular claim form, font size, or file format for electronic submissions. It’s important to review the guidelines carefully to ensure compliance with any formatting instructions.

Many insurance companies now offer online claim submission options. Check the guidelines or the insurance company’s website to determine if online submission is available and if there are any specific instructions for doing so.

The policy or the claim submission guidelines typically specify the timeframe for submitting a claim. Submitting the claim within the designated time frame is essential to avoid potential denials due to late submission.