• If an Encounter is unbalanced or missing the Primary Insurance adjudication, the Claim will not batch.
• The Primary Payment on the Claim must be posted correctly before it can be batched to send to the Clearinghouse, or the line items that do not balance must be excluded from the Secondary Claim.

Calculation Logic

When an electronic Secondary Claim is created, there is an ANSI loop that represents an EOB.

If one or more of the Encounters do not have a Primary Payment where the sum of IP, CO, and PR codes sum to the total line item Charge, it is rejected as not balanced.

• Calculation for balancing: Payment + Contractual Adjustment + Other Adjustments + Patient Responsibility = Charge amount
• Example:

• Charge =70.00
• IP = 33.81
• CO45 = 26.00
• CO237 = .88
• CO253 = .69
• PR2 = 8.62
• Calculation: IP    +    CO45 + CO237 + CO253 + PR2 = Charge Amount
•                      33.81 + 26.00 + .88     +     .69   +  8.62  = 70.00

• In the Claim Submission Queue, the unbalanced claims will display in Adjudication Unbalanced line.

Resolve the Unbalanced Line Item(s)

The fix depends on the reason the Claim is unbalanced.

• Select the number in the Encounters column to correct each one.

• A Message will be displayed on the Encounter Dashboard in the Balance panel above the Transactions stating why it is unbalanced.
• The line item that is unbalanced will be highlighted on the Encounter Dashboard.

No Primary Payment Posted on One or More Line Items

• If the Claim is partially paid or denied entirely, the unbalanced status could be a result of one of these scenarios:

• Nothing was posted on the denied line items; or
• The denied line items are posted as a Notes.

Resolution:

• Use Post Expert to post the zero payments and adjustments on the unpaid line; or
• Exclude the unpaid lines on the Secondary Claim.

• This results in the line items with no posted Payments staying in Primary responsibility, and the lines with Payments being sent to the Secondary Payer.

Insurance was changed after Payment

• The Claim may be unbalanced If a Payment was posted on a previously Active Insurance.
• Scenario: Insurance Profile on Encounter 123456 was Aetna/Medicaid/Patient.

• Aetna Payment was received and posted.
• Later, the Insurance Profile was changed to Anthem/Medicaid/Patient, and the Encounter was mistakenly moved to this new Profile.
• When the attempt was made to send the Claim to Medicaid, the Secondary Payer, it did not batch and was statused as unbalanced.

Resolution:

• Move the Encounter back to the Aetna/Medicaid Profile.

• If the Profile is not displayed on the Insurance Management screen, select Include Inactive Profiles.

• Batch the Claim again to send to the Secondary Payer.
  

Payer Adjustments

1. To correct this, create the ERA Management Rule "Charge=Allowed-Adjustments does not Equal $0" with the following criteria:
   

1. Claim Types: Primary [1], Primary Forwarded [19]

2. Criteria
   

1. Event: Charge - Allowed - Adjustments does not Equal $0
   

2. Exclude CARC from Unbalanced Calculation: Enter the CARC Code(s) that is causing the problem, such as: COA2,CO223,CO253,CO144,OA253,PI253,CO237 (No spaces between Codes, use commas to separate)

3. Exclude CARC from Unbalanced Calculation: Enter the CARC Codes that is causing the problem, such as: 

4. Action: Put on Hold
   

1. This ensures that any other CARC codes/adjustments that were not included will still trigger the rule and go on hold for further review.
   

• Remit Note: Enter a note (optional).
  

• Additionally, edit the System Setting ADJBALEXCL to include Manually Posted Payments.
  

• If neither of these solutions resolve the problem, review the line items to ensure the ERA was applied correctly and the funds balance.
  

• If the Claim is still unbalanced, contact Support.
  

Learn More

• Payments Category in System Settings: ADJBALEXCL