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Back  RFI # 532: Interpretation of TL PLB adj

Formal vs. Informal Help Informal Formal

Submitter

Sharon Sieve

Description

MO Medicaid is taking back pmts when they identify that the patient had Medicare coverage using the TL PLB adj. Our understanding is we cannot post the TL transaction at the account level. Is that correct? If so our account will always display Medicaid paid, when in fact they recouped the pmt. If we were to be audited the account would look as if Mcaid paid.
Should the hospital post the PLB transaction at the account level and if not is leaving the pmt on the account compliant?

Response

This issue is explicitly addressed in guide 004010X091. Section 2.2.8 explicitly identifies the requirements when a health plan changes their adjudication - in this case, when the plan identified that they are the secondary payer and not primary, the correction and reversal process MUST be utilized. In addition, the PLB segment code TL is explicitly related to Capitation payments per section 2.2.10 and can not be applied to this business.
Submission 3/15/2007
Status Date 5/25/2007
Status F - Final
Primary References
Document 005010X221
Section835
Page206
Set IDPLB