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Back  RFI # 253: WO PLB03-2 PROV ADJ ID INTERPR

Formal vs. Informal Help Informal Formal

Submitter

Sharon Sieve

Description

MCARE B -BC OF ARK INCLUDES AN INTERNAL CLAIM NBR THAT IS NOT A NBR THE FACILITY HAS ACCESS TO REFERENCE. THE WO OFFSETS A PREVIOUS FB PLB TRANSACTION. BUT THE FAC MUST CALL TO FIND OUR WHICH FB THE TRANSACTION REFERS TO. EVEN THOUGH WE ARE NOT POSTING THE FB OR WO AT THE ACCT LEVEL WE MUST RECONCILE. PLEASE REPLY IF THE PAYOR IS COMPLIANT. HOW CAN THE PROVIDER KNOW THE WO IS APPLICABLE IF NOWAY TO MATCH TO THE ORIG FB. THE REF ID NBRS ARE DIFFERENT IN THE FB AND THE WO TRANSACTIONS?

Submitter Assigned Keywords

WO PLB INTERPRETATION

Response

The 4010A1 does not explicitly cover the management of balance forward situations. The intent of the FB qualifier is to balance the transaction when the net of all claim/service level adjustments result in a negative amount. Since the associate dollar amount can be negative (moving dollars to the next 835) or positive (bringing dollars in from a previous 835), code FB should be used for both ends of the reconciliation. The use of code WO is unnecessary, and inappropriate, although not non-compliant.

Recommendation

Use code FB for both the forwarding of the balance and the subsequent ‘offset’. For reconciliation purposes, the same identifier in the associated ID element is both appropriate and necessary. Refer to section 2.2.12 of the 4050 version of the Claim Payment implementation guide for further detailed information on the balance forward process. The clarification presented in this version does not violate any rules under 4010A1. The guide can be purchased from WPC at http://www.wpc-edi.com/content/view/422/160/.
Submission 5/3/2005
Status Date 6/27/2005
Status F - Final
Primary References
Document 004050X124
SectionPROV ADJ
Page199
Set IDPLB