Remittance Balancing

30 - Remittance Balancing (Rev. 3288, Issued: 07-02-15, Effective: 08-03-15, Implementation: 08-03-15) For Medicare the principles of remittance balancing are the same for both paper and electronic remittance formats. Balancing requires that the total paid amount is equal to the total submitted charges plus or minus payment adjustments for a single ASC X12 835 remittance in accordance with the rules of the standard ASC X12 835 format. Refer to Front Matter Section 1.10.2.1 for Balancing in the ASC X12 835 version 5010 TR3. Every HIPAA compliant ASC X12 835 transaction issued by a MAC must comply with the ASC X12 835 version 5010 TR3 requirements, i.e., these remittances must balance at the service, claim, and provider levels. The flat files generated by the shared systems must be balanced at the line, claim, and provider level. As a failsafe measure claim adjustment reason code121 and PLB reason code 90 may be used at the line, claim, and provider level respectively to make sure that the ASC X12 835 is balanced. Shared System generated reports must track the usage of these codes, and A/B MACs and DME MACs must work closely with the shared system maintainers and CMS to resolve the issues resulting in out of balance situations.