Elements of a Clean Claim

Claims that do not contain the required elements will be rejected and the provider will be required to resubmit after making the necessary corrections. Elements of a clean claim are as follows:

  • Member name
  • Member number (Social Security Number)
  • Member date of birth
  • Provider tax I.D.
  • Provider NPI number (if applicable)
  • Provider name and address
  • Dates of service (If the claim is for multiple months of service, you must use a separate line for each month.)
  • Type of Bill code (if applicable) 
  • Modifier (if applicable)
  • Authorization number
  • Number of units of service provided (The number of days billed in the date span on a claim for daily unit services must match the number of day units billed.)
  • Total units cost

If the service provided is a Medicaid service, the clean claim must also be submitted in a format and coding system acceptable to Wisconsin’s Medicaid program.