How to reconcile a remittance line by line

Executive summary. Read what a payer actually paid against what each line should have paid, and see the adjustments that explain the difference.

Definition

Reconciliation compares each remittance line to the expected reimbursement and records the difference with the reason given for it.

What to do

Open the remittance. It lists the claims it paid, line by line, rather than as one total.

Read each line against what was expected. A matching total across a remittance can still hide two lines that are wrong in opposite directions.

Read the adjustment and its reason code where a line differs. The reason code is the payer telling you why, and it is what turns a shortfall into either an appeal or an explanation.

Anything unexplained opens as an exception, carrying the arithmetic with it.

What the system does first

The remittance file is archived verbatim before any segment of it is interpreted. If the interpretation is ever wrong, the original is still there to reinterpret, which is the same rule the dispensing feed follows.

Variance is computed net of the dispensing fee, so a line short by exactly the fee is not raised as a loss.

Frequently asked questions

Reconciliation is not available on my plan. What does that mean?

It is included with Margin + Audit. The refusal names the plan rather than saying only that you cannot, so you can tell the difference between a missing permission and a product you do not have.