Complete Claim Definition

Serra Community Medical Clinic, Inc will adjudicate complete claims. A complete claim is a claim, or portion of a claim, including attachments and supplemental information or documentation, that provides reasonably relevant information or information necessary to determine payer liability and that may vary with the type of service or provider. Reasonably relevant information means the minimum amount of itemized, accurate and material information generated by or in the possession of the provider related to the billed services that enables a claims adjudicator to determine the nature, cost, if applicable, and extent of the plan’s liability, if any, and to comply with any governmental information requirements. Information necessary to determine payer liability means the minimum amount of material information in the possession of third parties related to a provider’s billed services that is required by a claims adjudicator to determine the nature, cost, if applicable, and extent of the plan’s liability, if any, and to comply with any governmental information requirements. In addition, the plan may require additional information from a provider where the plan has reasonable grounds for suspecting possible fraud, misrepresentation or unfair billing practices.