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Back  RFI # 2223: PLB Reference Number

Formal vs. Informal Help Informal Formal

Submitter

mike sunderland

Description

I have a payer that uses WO exclusively even when moving a balance forward. My issue is that the reference numbers dont match so I'm not able to track when they're offset. I've contacted the payer and they said the first WO references the original claim number and the second WO to offset it,references the reprocessed claim number. In the guide it states the reference numbers must match but its exclusive to the FB PLB. Is the payer adhearing to the guidelines? Does the reference numbers have to match even when sending WO's in place of a FB? how is the provider to track when these are offset if the reference numbers are different?

Response

In the 005010X221A1 guide, section 1.10.2.12 lays out the proper way to move a negative payment/balance amount forward into a future payment. “When a net negative payment is detected in an 835, this is corrected by adding a balance forwarding adjustment in the PLB segment.” If this is the business case, then the FB qualifier must be used and the identifier must match between PLBs.

If that isn’t the business case, then the 005010X221A1 guide, section 1.10.2.17 lays out the proper usage of the WO Adjustment Reason Code and Reference Identification for use in claim overpayment recovery.

In the case where the overpayment is not being recovered within the 835 the guide explicitly states “Within the same 835, a PLB segment is then used to return the funds to the provider and NOT reduce the current payment. This is effectively delaying the recovery of funds within the 835. The FCN reported would be the health plan's internal control number for the claim involved in the recovery (CLP07).”

Recommendation

It is recommended that you investigate if overpayment recovery is actually what the Payer is trying to communicate, or if they need to change their Adjustment Identifier.
Submission 7/28/2017
Status Date 1/25/2018
Status F - Final
Primary References
Document 005010X221
Section1.10
Page48