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Back  RFI # 2078: L6 in WO PLB total

Formal vs. Informal Help Informal Formal

Submitter

Sharon Sieve

Description

Medicare is including Interest penalty within the WO PLB qualifier. the WO includes the clm pmt recoupment and addl interest penalty. The Provider must call the payer to find out what the discrepancy is for. Is it compliant for the payer to mix the recoupment and interest in the WO plb? Or should there be two plb's one L6 and one WO?

Submitter Assigned Keywords

PLB WO w interest included

Response

The PLB adjustment code WO (Overpayment Recovery) is defined in a note as "The recovery of previous overpayment." Understanding that the interest in question is an assessment on the provider for the time that the overpayment was in the possession of the provider and was never paid to the provider, inclusion of an interest penalty within a PLB adjustment identified by qualifier WO is not appropriate.

PLB adjustment code L6 (Interest Owed) is defined in the note as "This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I"." The interest referenced does not apply under that definition as it is not "paid on claims in this 835".

The guide provides no explicit mechanism within section 1.10.2.9 (Interest and Prompt Payment Discounts) or 1.10.2.17 (Claim Overpayment Recovery) or the existing PLB codes to handle this assessment of interest on an overpayment.

Recommendation

This is a new business need and should be submitted as a change request to ASC X12 at http://changerequest.x12.org/.

In the interim, the payer should consider reporting the related interest in the PLB segment using Adjustment Code CS, a reference identification that matches that used in the related WO adjustment, with a suffix like "INTEREST", and a positive dollar amount for the amount of the interest being collected.
Submission 7/31/2015
Status Date 9/21/2015
Status F - Final
Primary References
Document 005010X221
Section1.10.2