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Back  RFI # 2241: Adjustment Reason Code OB

Formal vs. Informal Help Informal Formal

Submitter

Lucy deWahl

Description

The client, a hospital with their own self-funded health plan, has requested that for payment of their internal claims (where the hospital is both the payer and the payee) they receive a remittance only and that there be no movement of funds.

It appears that this could be accomplished by communicating a provider level adjustment in the 835 in PLB04 in an amount that reduces the total payment (BPR02) to $0 and using adjustment reason code OB ‘Offset for Affiliated Providers’ as the value of PLB03-01.

Can you please confirm that in the scenario described the hospital would be considered an 'Affiliated Provider' and that it would be appropriate for them to use provider level adjustments to reduce their total payment amounts to $0 in order to avoid paying themselves?

Submitter Assigned Keywords

PLB03, Adjustment Reason Code, Offset for Affiliated Providers, 835, OB

Response

The PLB - PROVIDER ADJUSTMENT Segment is “Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send.” While X12 cannot comment on whether this is or is not an “Affiliated Provider” scenario, it is compliant with the 005010221A1 TR3 to use the PLB segment to report provider level adjustments to zero out the payment.

Submission 10/9/2017
Status Date 11/17/2017
Status F - Final
Primary References
Document 005010X221
Section2.4
Page221
Set ID835
Segment IDPLB
Element Position03
Component Position01
Industry NameOffset For Affiliated Provider
Code ValueOB