Executive summary. Find the shortfall, read the arithmetic behind it, and work it until it is settled or explained.
Definition
An underpayment is the difference between what a claim should have paid under the contract and what the remittance actually paid.
What to do
Open the exceptions worklist. Each row is a line the remittance paid differently from what was expected.
Read the arithmetic on the exception. It carries what was expected, what arrived, and the difference, so you are not recomputing it while you are on the phone.
Check the variance is net of the dispensing fee. A line can look short by exactly the fee and be correct, and that is the most common false alarm.
Work the exception: record what you found and what you did. It stays on the worklist until it is settled or explained.
Where this legitimately goes different ways
Some shortfalls are correct. A contract term you had not applied, a patient responsibility, or an adjustment with a reason code that explains it. Recording that explanation closes the item honestly, and it stops the same line being chased again next month.
A shortfall that repeats across many lines of one payer is a contract conversation, not a claim conversation. The individual exceptions are the evidence for it.
Frequently asked questions
Why does the variance not match my own subtraction?
The figure is net of the dispensing fee. Comparing the paid amount to the contract rate alone will look short by the fee on almost every line.
Referenced standards and further reading
- Attergo Knowledge Center ↗Attergo
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