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Back  RFI # 2231: Refund with Payer Letter

Formal vs. Informal Help Informal Formal

Submitter

Andrew Lee

Description

We have an issue where the payer sends our provider a letter stating a refund needs to occur for a certain patient and service date. If the provider does nothing, the payer, according to the spec, will take the refund in a future 835. They do that by sending a single WO PLB. The issue is on the 835 they dont indicate in a CLP segment that they are taking the money from which patient. The only money moving is the PLB. I would expect a reversal CLP segment, and negative PLB FB to put the money aside, and a positive WO PLB to take the money back. PLBs have always had to balance out, but it seems the spec in unclear on this situation on how the payer has to balance the PLB.

Submitter Assigned Keywords

PLB Refund

Response

This is addressed in section 1.10.2.17 Claim Overpayment Recovery. If a provider does not remit the overpayment, then the health plan will recoup the funds from a future payment. The recoupment is reported using a PLB segment with code WO (overpayment recovery) not the reversal and correction procedure. The reversal and correction process is not used since the provider’s system may have already been updated to reflect the recoupment based on the letter.

When reporting a recoupment in the PLB segment, the payer includes the financial control number (FCN) from the refund letter in the PLB03-2.
Submission 8/25/2017
Status Date 12/1/2017
Status F - Final
Primary References
Document 005010X221
Section1.10.2
Page48