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Back  RFI # 1374: PLB Overpayment Recovery

Formal vs. Informal Help Informal Formal

Submitter

Dora Lambert

Description

A majority of our overpayment recovery is done using reversal and correction. As a result, a forward balance (FB) is sometimes created in the PLB segment. Occasionally a provider will remit the FB amt by sending in a check. When this occurs, what should the PLB segment look like? Here is an example:

Week
1-$100 claim pd and $1000 claim pd.
2-$100 claim reversed and then subsequently denied. No other claims pd during cycle, leaving a FB of $100.
3-$1000 claim reversed and then subsequently denied. No other claims pd during cycle, leaving a new FB of $1100.
4–Provider submits 2 checks to payer, for $100 and $1000. What should the PLB segment look like for week 4? Would it look like this:

PLB{XXXXXXXX{20111231{72|REFCHK0224{-100
PLB{XXXXXXXX{20111231{72|REFCHK0225{-1000
PLB{XXXXXXXX{20111231{FB|IDENTIFIER FM WK 3{1100

Or, does the process of the provider remitting the funds without the payer initiating the refund (Section 1.10.2.17) apply in this situation? If so, what would the PLB look like?

Submitter Assigned Keywords

PLB Overpayment Recovery

Response

The situation described relates to having received a check to satisfy a balance forward and not related to an Overpayment Recovery. The related overpayment recoveries, as such, were satisfied in the prior 835s. Version 5010 does not include any direction related to receiving a check as a result of a balance forward. As a result, there is no requirement under the guide to provide acknowledgement of the check received or to report the now satisfied balance forward. From a general business perspective, providing that acknowledgment is consistent with the principles described within the Balance Forward and Overpayment Recovery sections of the guide. See the recommendation section for suggestions on how to report this information.

Recommendation

If a health plan desires to acknowledge the satisfaction of the prior balance forward and receipt of the check(s), then the contents of the PLB depend upon the details of the refund. PLB Adjustment Reason Code 72 (Authorized Return) would be used to report the check received.

Assumption reflects two checks for the individual overpayments as outlined in the question

The current balance forward is for $1100 and has a reference number of 123456

The provider remits two checks, one for $100 identifying claim #98765, and the second for $1000 identifying claim number 765432

The related PLB segment would look like:

PLB*XXXXXXXXXX*12312011*FB:123456*1100*72:98765*-100*72:765432*-1000~

In both cases, the forwarding balance and the received check(s) are reported and the net of the related PLB entries is zero.
Submission 8/3/2011
Status Date 9/27/2011
Status F - Final
Primary References
Document 005010X221
Section1.10.2.1
Page48
Table3
Segment Position0100
Segment IDPLB