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Back  RFI # 2131: Incomplete PLB Transactions

Formal vs. Informal Help Informal Formal

Submitter

Andrew Lee

Description

A payer is using PLB's to send HSA payments. This is not inherently wrong, but they are not completing the transaction.

On the Insurance Payment, they make their payment, and use a OA-187 to denote an amount that will be paid by the HSA account. On the same 835, there is a CV PLB for that amount and the Reference Element in PLB03-2 contains the CLM01 of the claim we are to attach that money to. The PLB is a Provider Level transaction, not a patient level, so the PLB03-2 should not be used to denote the movement of money inside the PMS. The Spec only says that it's an Identifier, not a payment. The HSA money is a payment and needs to be as such on the 835. I have called the payer and they said this is considered completed in their system and nothing else is set to happen.

I'd like a ruling that the payer cannot use the PLB03-2 and expect the provider to use that to make a payment to the Patients charge in the PMS

Submitter Assigned Keywords

PLB HSA

Response

RFI 1670 described three ways to handle consumer spending account payments. The ‘All in One Model’, where the Health Plan is the Spending Account manager, uses a single 835/EFT to report both the healthcare insurance payment and the Spending Account payment in the same CLP. This is the applicable model for the situation you describe.

The Spending Account payment is reported using CARC 187 (Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)). As shown in RFI 1670, the adjustment amount is negative to reflect a payment and it appears in the same CAS segment as the patient responsibility it is offsetting.

You provided the following example of an 835 you are receiving (abbreviated to show relevant elements):

ST*835*0002

BPR*I*192.8*C*ACH*…

CLP*pan*1*375*0**12*pccn*…

SVC*HC:99214*375*0**1

CAS*OA*187*192.8

CAS*CO*45*182.2

AMT*B6*192.8 …

PLB*npi*20161231*CV:pan*-192.8

SE*35*0002

It is not appropriate to use the CAS*OA (Other Adjustment) for a patient responsibility amount, nor is it appropriate to use the PLB/CV (Capital Passthru) for a consumer spending account payment. The appropriate way to show this payment follows:

ST*835*0002

BPR*I*192.8*C*ACH*

CLP*pan*1*375*192.8**12*pccn*

SVC*HC:99214*375*192.8**1

CAS*PR*1*192.8**187*-192.8

CAS*CO*45*182.2

AMT*B6*192.8

SE*35*0002
Submission 3/2/2016
Status Date 4/22/2016
Status F - Final
Primary References
Document 005010X221
Section1.10.2.5
Secondary References
RFI ID 2607
Document 005010X221
Section1.10.2.4