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Back  RFI # 2186: payment prior claim submission

Formal vs. Informal Help Informal Formal

Submitter

Barber Meg

Description

When card (payer issued memb) is used at time of service for payment, the claim later submitted to payer. If the card Swipe is greater than allowed the provider owes refund to the payer. Should this be handled at the PLB level when the claim is received /adjudicated?
When the CLP02 = 1 and the provider for that claim has been previously overpaid can the CLP04 and SVC03 be reported as negative? (I do not believe this is comp.,need confirmation)
If we can’t off set the check by this negative CLP then a PLB would then be required (WO or FB?)) OR
Should the CAS show the total amount previously paid (CO 193 or new CARC) and then a negative cas for the amount owed (CO B13 -$). The SVC03 and CLP04 would be zero. The negative amount would then show as a PLB to be clipped at the check level of that given remit or if no funds will show as a Forward balance. (WO if we clip and WO/FB if we need to offset future remit)
Note: this negative may be at the line level SVC03 but the overall claim may not be a negative

Submitter Assigned Keywords

SVC03 CLP04 negative

Response

Overpayments that result from card charges collected at the time of service are to be reported in the PLB segment. If the overcharge amount is greater than the current payment amount then payer may use a forward balance to collect funds from a future payment. When the provider has accepted payment at the time of service, the payment amount is to be reported using CARC B13 “Previously paid. Payment for this claim/service may have been provided in a previous payment”. If the payer determines that the service was overpaid then the overpayment amount is to be reported using CARC 129 “Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)” with RARC N199 “Additional payment/recoupment approved based on payer-initiated review/audit.”

Recommendation

If the CARC or RARC does not meet the exact need for this situation, you may submit a request for new code(s).
Submission 12/15/2016
Status Date 3/18/2017
Status F - Final
Primary References
Document 005010X221
Section1.10.2.1
Page48
Set IDPLB
Loopsummar