RFI Browser

Back  RFI # 227: Clarifiication 835 corr/rev

Formal vs. Informal Help Informal Formal

Submitter

Denni O'Donnell

Description

We have a situation with the 835 that we need help with. The 835 transaction shows a reversal of the line items (CLP02 = 22) but the validation software we are using balanced the claim with the PLB segment instead of an additional CLP segment. Page 164 of the 4010A1 835 IG specifically states "Use the PLB segment to allow adjustments that are NOT specific to a particular claim or service to the amount of the actual payment."

We questioned our vendor on this issue and the response was:
"We have not found any language in the 835 IG to indicate that the correction and reversal must appear within the same transaction. This claim would merely revert to a pending status, awaiting a future remittance. If you find language requiring the correction and reversal be contained in the same transaction, please let us know."

We are asking for direction from X12 on how this correction and reversal should flow.

Response

The ability to reverse a claim in one remittance and correct it in another is allowed under the 4010 implementation guide. If this is done, however, the money is automatically recouped. To not recoup the money, the PLB segment must be used with PLB03-1 codes WO (Overpayment Recovery) and a negative dollar amount in the current 835. When the correction is sent, the WO entry must be used again with a positive value (same dollar amount) to offset the original payment. Use the claim number as the PLB03-2 reference number to tie the information together

Recommendation

It seems as though processing the reversal in one remittance and the correction in another causes a good deal of additional logic that would not be necessary if they were communicated together. We suggest that you attempt to keep them together or review in greater detail the Overpayment Recovery section in the 4050 guide http://www.wpc-edi.com/content/view/422/160/. That provides extensive additional information.
Submission 3/24/2005
Status Date 5/16/2005
Status F - Final
Primary References
Document 004010X091A1
Section2.2.8
Page164
Set ID835
Loop2100