ECP observes that many
rejections of secondary claims are the result of secondary claims
being "out of balance". Secondary claims need to
balance at the both claim-level and the line-level. Below is a
brief overview of how properly balanced secondary claims are
determined.
CLAIM-LEVEL BALANCING:
Claim-Level
Payer Paid Amount
+ All
Claim-Level Adjustment Amounts (i.e. Contractual Obligations,
Patient Responsibility, etc.)
+ All
Line-Level Adjustment Amounts (i.e. Contractual Obligations,
Patient Responsibility, etc.)
--------------------------------------------------------------------------------
= Total
Claim Charge Amount
EXAMPLE:
Primary payer paid a total of
$70
Made a $10 coinsurance
adjustment on the first service Line
Made a $20 contractual
obligation adjustment on the second service line
--------------------------------------------------------------------------------
Total Claim Charge Amount is
$100.00 ($70 + $10 + $20 = $100)
LINE-LEVEL BALANCING:
Line-Level
Payer Paid Amount
+ All
Line-Level Adjustment Amounts (i.e. Contractual Obligations,
Patient Responsibility, etc.)
---------------------------------------------------------------------------------
= Line Item
Charge Amount
EXAMPLE:
Primary payer paid $65 on the
first service line
Patient responsibility amount
of $10
---------------------------------------------------------------------------------
First Line Item Charge Amount
is $75 ($65 + $10 = $75)
Primary payer paid $5 on the
second service line
Contractual obligation amount
of $20
---------------------------------------------------------------------------------
Second Line Item Charge Amount
is $25 ($5 + $20 = $25)
Note:
Any & all line-level services with secondary adjustments must
independently balance
If you have any questions,
please contact ECP at 800.327.1213.
Sincerely,
ECP
415 Greenwell Ave.
Cincinnati, OH 45238
800.327.1213
www.4ecp.com
