Resolve Insurance Claims Out of Balance

  • Updated

Claims become out of balance when the sum of the covered and non-covered amounts is greater than the charged amount on the claim. Claims most often become out of balance when more than one remit is received for a single claim and the balance becomes negative. Reversals can efficiently correct claims out of balance for this reason.

Identify Claim Out of Balance

The workflow begins when remits are posted to a claim and the sum of those remits exceeds the charged amount on the claim. A review may also be necessary if the patient's responsibility exceeds the billed charges.

  1. To locate out-of-balance claims, navigate to the Management Center > Organization Dashboard.mceclip1.png
  2. From the Insurance Payments section, click on the Insurance Claims Out of Balance tile.mceclip0.png
  3. This tile takes users to the Insurance Claims Out of Balance tab. mceclip2.png

Users can also navigate here directly by following this path: Work Center > Insurance Payments > Insurance Claims Out of Balance.

Review Reasons

Address balance issues from the Insurance Claims Out of Balance tab. From this screen, balances can be ignored or resolved. This screen also details the reason a claim is unbalanced. The possible Review Reasons are:

  • Negative Balance: The remits posted to the claim equal more than the total claim charged amount.
  • Patient Responsibility Greater than Billed Charges: Per the posted remits, the sum of the patient's responsibility (deductible, coinsurance, PR adjustments, and paid to patient) exceeds the total claim charged amount.

Resolve Out-of-Balance Claims

  1. Ignore is appropriate if the payer will send an offsetting ERA, the balance is accurate, or the claim does not need to be corrected.
  2. Clicking Resolve navigates to the claim’s Payments tab, where you can take action to resolve the issue.
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    • This is where users will evaluate the best way to correct the negative balance.
    • When a claim receives a remit and becomes unbalanced, it is automatically moved to the Balance Review Queue in the Work Center. This is helpful for assigning and managing unbalanced claim follow-ups.mceclip4.png

How to Balance Claims and When to Apply a Reversal

From the Insurance Claims out of Balance tab, click Resolve to the right of the unbalanced claim that requires review.  mceclip4.png

Once inside the claim’s payments tab, look at the top of the page for the summary of the claim balance.

Example 1: Two Nonpaymentsmceclip5.png

In the image above the claim has a -$125 balance. At the bottom of the screen, information is summarized about all remits posted to the claim. mceclip6.png

Here, users can see that the claim is out of balance because the total claim charged amount of $125 is accounted for twice by two separate remits.

Claim Balance Cycle:

  1. The claim is submitted with a charged amount of $125. The balance of the claim is $125 because there are no postings accounting for any of those charges.
  2. On 3/2/18, a remit is received for the claim. The remit assigns $125 to adjustment PR-22. Since this remit accounts for the total claim charges, the balance of the claim goes to $0.
  3. On 9/1/18, the payer issues a new decision, and another remit is received for the claim. The remit assigns $125 to adjustment PR-97. Since this remit also accounts for the total claim charges, the balance of the claim goes to -$125.

Determine which payment to reverse, by considering what the payer truly allowed on the claim. If more than two ERAs have been sent for one claim, multiple reversals may be necessary to correct the balance. In this example, since both remits are nonpayments, without coinsurance or deductible, a reversal should be applied to the oldest remit. The oldest remit represents a decision that was effectively overturned when a more recent remit was sent. Applying a reversal negates the impact that the remit has on the claim’s balance. Reversals should be applied to remits that no longer represent the payer’s decision. It may be necessary to contact the payer to determine which remit currently represents their decision. The current decision may not always be the most recently dated remit.

Resolving the Imbalance

  1. Click Apply Reversal to the right of the 3/1/18 remit.mceclip7.png
  2. Click Confirm.
  3. A new line will be posted showing the inverse of the 3/1/18 decision.mceclip5.png
  4. The balance of the claim total and line items will revert to $0.
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Example 2: A Payment and a Nonpaymentmceclip10.png

In the image above the claim has a -$200 balance. At the bottom of the screen, information is summarized about all remits posted to the claim.mceclip11.png

Here users can see that the claim is out of balance because the full claim charged amount of $200 is accounted for twice by two separate remits.

Claim Balance Cycle

  1. The claim is submitted with a charged amount of $200. The balance of the claim is $200 because there are no postings accounting for any of those charges.
  2. On 6/11/18, a remit is received for the claim. The remit assigns $100 towards an adjustment and pays $100. Since this remit accounts for the total claim charges, the balance of the claim goes to $0.
  3. Also on 6/11/18, another remit is received for the claim. The remit puts $200 towards an adjustment. Since this remit also accounts for the total claim charges, the balance of the claim goes to -$200.

Determine which payment to reverse, by considering what the payer truly allowed on the claim. If it is not clear, call the payer. In many cases, a payment made in error will be followed by a recoupment and will not require a reversal. Adjustments often do not result in offsetting ERAs. Reversals are designed as an efficiency to post offsetting charges when the payer does not submit an offsetting ERA. It should be used in these scenarios only. To balance the claim in the above example, a reversal would be applied to the top check.

Resolving the imbalance:

  1. Click Apply Reversal to the right of the nonpayment.
  2. Click Confirm.
  3. A new line will be posted showing the inverse of the decision.
  4. The balance of the claim total and line items will revert to $0.

If a reversal is applied in error, click Unapply Reversal. This will return the check to its original state.
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Best Practices

  • For more detail, click on the check number. Do this before applying a reversal if it is unclear which remit should be reversed.
  • Address imbalances only after all postings have been made to a claim. Before correcting for a balance issue, ensure there are no payments waiting to be matched to the claim.
  • Do not apply a reversal if the payer is sending a recoup. Wait to receive and post the recoup.
  • Do not apply reversals in anticipation of a future decision. Wait for the claim to be fully processed with all remits received.

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