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Definition of a Clean Claim

A "clean claim" means a claim that does all of the following:

  1. Identifies the health professional, health facility, home health care provider, or durable medical equipment provider that provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.
  2. Sufficiently identifies the patient and health plan subscriber.
  3. Lists the date and place of service.
  4. Is a claim for covered services for an eligible individual.
  5. If necessary, substantiates the medical necessity and appropriateness of the service provided.
  6. If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.
  7. Identifies the service rendered using a generally accepted system of procedure or service coding.
  8. Includes additional documentation based upon services rendered as reasonably required by the health plan.

MCL 500.2006(7) to (14) and MCL 400.111i for Medicaid clean claims