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Back  RFI # 1082: 835 Overpayment Compliancy

Formal vs. Informal Help Informal Formal

Submitter

Jan Klimper

Description

If we send an overpayment recovery notification letter, (as a result of the Managed Care Settlement), in addition to a reversal and correction record in the 835 with the proper PLB WO and FB usage, are we out of compliance? The TR3 states "The health plan may use a combination of methods 1 and 2 for overpayment recovery." (Section 1.10.2.17)

Submitter Assigned Keywords

835 Overpayment Recovery Compliance Notification Letter

Response

This issue is explicitly addressed in guide 005010X221. The referenced section identifies the combination of method 1 and 2 as using the reversal and correction process and delaying recoupment to allow the provider to send a check.

Section 1.10.2.17 also states under option # 2 "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."

Sending a letter, plus reversal and correction of the related claim is not allowed.
Submission 6/24/2010
Status Date 8/26/2010
Status F - Final
Primary References
Document 005010X221
Section1.10.217
Page48
Set ID835