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Back  RFI # 1013: Claim Level Refunds in 5010

Formal vs. Informal Help Informal Formal


Brian Wagner


For overpayment recovery, we either follow scenario 1 or do a variation of scenario 2. For scenario 2, we send letters that show the overpaid claims. Most of our providers refund by claim and want the corrected claims data to reconcile their A/R by patient. We have a process to adjust the provider's overall balance using offsetting WO/72 adjustments, but were asked not to use it because providers weren't sure how to post the info to patient accounts.

Because of this, when we receive a provider refund, we backout and replace each overpaid claim. We also use a PLB with a 72 qualifier and a negative amount to show the provider's refund. We also show the backout claim number as the ref number in the PLB03-2.


We believe that other health plans and CMS follow this procedure as well. Is this HIPAA compliant for 5010? If not, can you suggest options that address our providers' concerns?

Submitter Assigned Keywords

PLB 72 WO 5010 Refunds Overpayment Recovery


This issue is explicitly addressed in guide 005010X221. Section identifies the specific requirements and options. That section states under option 2 "This process involves sending a letter identifying the claim, the changes to the adjudication, the balance due to the health plan and a statement identifying how long (or if) the provider has to remit that balance." and "This is accomplished using the PLB segment, and NOT the reversal and correction procedure. Reversal and correction is not appropriate since the provider's system has already been updated manually to reflect the adjudication changes."

Therefore, the approach of sending a letter for a batch of claims, and then using the reversal and correction process is not consistent with the guide.

(continued in Recommend below)


(continued from Response above)

When the receipt of the check is acknowledged, or the overpayment is recouped because a check was not received, that is no longer related to the claim. It is a receivable to the payer that is not claim specific. The changes to the claim in the provider's system occurred when the letter was received.

This guide establishes the standard for this process that applies to both payers and providers

If the provider wants the detail plus ability to review and hold off the repayment – then option 3 in the guide could be considered by the payer.
Submission 4/1/2010
Status Date 5/21/2010
Status F - Final
Primary References
Document 005010X221
Set ID835
Segment Position0100
Segment IDPLB
Element Position03
Component Position1
Industry NameOverpayment Recovery
External Code ListPLB Adjustment Reason Code
Code Value72 WO