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Back  RFI # 1835: Recovery from other entity

Formal vs. Informal Help Informal Formal

Submitter

Barber Meg

Description

The 835 TR3 guide in the overpayment and recovery section does not describe how to handle overpayments received from another payer (not the one orignally paid).. The PLB Adjustment reason codes also are not clear on what is the best code to identify refund received from other Source.
We have business situation as such: Claim is paid to Provider X for 100. Later it is identified that it is Workers Comp related. The Provider does not send us the refund,The workers comp insurer sends us the refund. In the past when we have sent a 'corrected' 835 showing the claim is WC and 'denied by us and show in a PLB the refund. The provider has no undstanding that WC refunded the money to us - they get confused In reality the provider is still made whole as no monies are recouped from them. The provider then bills the member.. 1 Are we required to acknowledge these refunds from WC in the ERA (with the corrected cliam) to the provider and 2 how can this be accuratly relayed in the ERA?

Submitter Assigned Keywords

Overpayment and Recovery from other payer

Response

The 005010X221A1 835 technical Report Type 3 does not address provider reporting when the non-priority payer is directly reimbursed by the priority payer.

The non-priority payer does not generally use an 835 to report this payer-to-payer transaction to the provider. The non-priority payer may notify the provider via letter or other communication.

However, the priority payer will account for the payer-to-payer refund when reporting its adjudication to the provider. In its 835, the priority payer will use Claim Adjustment Reason Code 195 (Refund issued to an erroneous priority payer for this claim/service).
Submission 7/31/2013
Status Date 10/25/2013
Status F - Final
Primary References
Document 5010X221
Section1.10.2.1
Page48
LoopPLB
Segment Position0100
Segment IDPLB
Element Position03
Industry Nameadjustment reason code