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Formal vs. Informal Help Informal Formal

Submitter

Chip Evelsizer

Description

There are situations where an overpayment of a bill/claim has occurred, and there are no expected additional future payments to be made relating to the same claim event.
There are times when the provider does send the overpayment back to the payer and sometimes not.
What are the data reporting requirements within the 835 transaction that will tie the payment back to that specific bill/claim and not to a general forward balance? What transaction exchange process is either required or recommended when the 835 is used?

This scenario often occurs for Property and Casualty claim processing, but may occur in other business scenarios.

Submitter Assigned Keywords

Overpayment 835 Recovery PLB

Response

Refer to sections 1.10.2.17 Claim overpayment Recovery and 1.10.2.8 Reversal and Corrections sections for direction on how to handle overpayment situations.

Recommendation

The situation described only results when the 835 is for a single provider and member relationship and for industries like Pharmacy or Property & Casualty where the ability to collect the funds from "other" payments is prohibited.

In this situation, the standard Reversal and Correction process is used to report the reversal and correction that results in an amount owed to be reported in the PLB using qualifier WO (Overpayment Recovery), and the value from CLP07 in the Reference Identifier.

The Payer, in this case P&C, can format the value in CLP07 of the corrected claim to accommodate their business needs. One proposal includes combining the words "PAYMENT DUE" along with the bill/claim identifier-CLP01.

In some business scenarios, the actual recovery of the dollars owed will be handled by a recovery unit or collection agency, and no further 835 activity is expected. In other business scenarios, the provider will send in a check which the payer will acknowledge using the PLB qualifier 72 (Authorized Return) along with the WO (Overpayment Recovery), which is the standard process for acknowledging receipt of a check.

If the provider does not remit the full amount owed, then recovery of the remaining amount would require a manual process outside the 835 transaction.
Submission 9/29/2014
Status Date 12/23/2014
Status F - Final
Primary References
Document 005010X221A1
Section1.10