Claims
Clean Claim Starter Checklist
A practical pre-submission review for reducing avoidable claim errors, rejections, denials, and rework. Covers eligibility, patient information, provider setup, authorization, coding and diagnosis review, modifiers, payer-specific requirements, and final claim scrub.
This individual form is free to access. No account or email required.
What this form is used for
Running a structured pre-submission review across eligibility, demographics, provider setup, authorization, coding, modifiers, payer-specific edits, and final scrub.
When to use it
Before any claim leaves the practice or billing service — especially for new staff, new payers, or services with high denial risk.
What to include
- Eligibility and benefits verified for the date of service
- Patient demographics match payer records
- Provider NPI, Tax ID, and enrollment confirmed
- Prior authorization or referral on file when required
- CPT, HCPCS, and ICD-10 codes valid and supported by documentation
- Correct modifiers applied for the service and payer
- Payer-specific edits and rules reviewed
- Final scrub before submission
Common mistakes to avoid
- Skipping eligibility re-verification
- Not checking payer-specific edits
- Missing or invalid modifiers
- Submitting without confirming authorization is valid for the DOS
Disclaimer: MedicalBillingForms.com is an independent educational resource and is not affiliated with CMS, Medicare, Medicaid, NUCC, NUBC, or any insurance payer. Official form requirements may change. Always verify current forms, instructions, and submission requirements with the official agency, payer, clearinghouse, or practice policy before submitting claims or using templates.
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