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Back  RFI # 1604: Negative Balances on 835

Formal vs. Informal Help Informal Formal

Submitter

Jennifer Delmont

Description

I am requesting X12 WG's intent of section 1.10.2.12 regarding balance forward processing. Are payers required to use the PLB to offset money as a result of a negative balance or are they permitted to show the offset by repeating a claim in the CLP that was previously negated in a prior 835? For example
Remit A
Claim 1 pays 600
Claim 2 adjusted and original payment of 800 is reversed resulting in a 200 negative balance.

Remit B
Claim 3 pays 50

Question is on remit B are payers required to offset that 50 in the PLB to reduce the negative balance to 150 OR can they show Claim 2 again from Remit A with a - 50 in CLP04 (even though -800 was already in RemitA). By repeating Claim 2 no PLB is created in Remit B.

Response

This issue is explicitly addressed in guide 005010X221. Section 1.10.2 states "This section and all subsections identify the business structure of the 835 and specific solutions or usage that relate to health care claim payment and remittance business issues. ... They are the only solutions for the business situations identified that are compliant with this implementation guide. Creation of 835 transactions that are not consistent with the information here is prohibited under this implementation."

Section 1.10.2.12 (Balance Forward Processing) identifies the process to be used when the scenario for Remit A occurs, and that process requires usage of the PLB segment in both Remit A and Remit B. Repeating Claim 2 in Remit B is inconsistent with those instructions and is, therefore, not allowed.
Submission 6/12/2012
Status Date 7/13/2012
Status F - Final
Primary References
Document 005010X221
Section1.10.2.1
Page36