The clean claim playbook: checks that stop denials before submission
Most denials are decided before the claim leaves your building. These are the checks our coders run on every claim before it is filed.
A denial is rarely a payer surprise. It is usually the result of a preventable data gap — a missing modifier, an expired authorization, a mismatched diagnosis. Building a clean claim means checking those gaps before submission, not after.
Verify eligibility before the visit
Confirm coverage, member ID, group ID, coverage dates, copay, deductible and coinsurance before the patient is seen. Eligibility and benefits verification is the first and most critical step in the billing process.
Confirm authorization and referral requirements
Match the authorization to the scheduled service and to the CPT codes billed. Flag any variance before charge entry rather than discovering it in a denial.
Check diagnosis support and modifiers
Load payer-specific medical-necessity policies for your highest-volume codes, and review bundling and modifier use against the actual documentation.
Watch the clock
Timely filing is unforgiving. Claims should move through a daily submission queue with enough time to correct and resubmit before the filing limit is at risk.
Measure what you catch
Track how many errors each check catches each week. If a check stops catching anything, something upstream changed — your checks are the early warning system for the whole revenue cycle.
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