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Back  RFI # 578: 835 Prov level adjust - recoup

Formal vs. Informal Help Informal Formal

Submitter

Betsy Clore

Description

Shouldn't only 1 claim be included in a WO overpayment recovery provider level adjustment? A payer is including multiple claims/patients in 1 recoup. The original claim payment is negated with a 22 correction (CLP07 is original payer CCN), followed by the adjusted payment (different payer CCN). The debit is offset with a PLB adjustment (identifier:original payer CCN, qualifier:FB) to prevent the recoup. Usually a letter is sent the same day listing only member ids, payer CCNs of original payments & service dates for multiple claims/patients & a single total recoup amount, saying that it will be taken later if not refunded by a certain time. A 2nd letter is sent at that time with a different financial control number & including the 1st letter, warning the recoup will be taken. When it is, the PLB adjustment is for the lump sum & identified with the FCN on the 2nd letter. Even if this method included 1 claim, shouldn't the id of the WO recoup match that of the PLB adj preventing the recoup on the 1st 835?

Submitter Assigned Keywords

835 PLB overpayment recovery recoup

Response

This issue is not explicitly addressed in guide 004010X091. The guide gives no direction except that idendifying numbers should be used. The intent was that identifying numbers would be used to facilitate reconciliation in whatever process was involved.

Recommendation

Subsequent guides provide specific instructions in this area. Use of Code FB for the delay of the recoupment is not part of those instructions. The use of FB is for a totally different process that is explained in guide 005010X221 in section 1.10.2.12. For the delay in recoupment, code WO would be used with a negatiove dollar amount to delay recovery of the money. There would be a separate PLB/WO entry for each claim recoupment delay. Each would use the value from the related CLP07 as the FCN. When the eventual recovery is taken or the payment acknowledged, a PLB/WO entry for the positive dollar amount and the same FCN is sent. The FCN is critical to the reconciliation process and must be identical in the delay and the recoupment. See TR3 005010X221 section 1.10.2.17 for more details.
Submission 7/13/2007
Status Date 10/22/2007
Status F - Final
Primary References
Document 04010X091A1
Section3.1
Page165
Set ID835
Table3
Segment Position010
Segment IDPLB
Element Position03
Industry NameAdjustment identifier