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Back  RFI # 758: 835 unexpected refund

Formal vs. Informal Help Informal Formal

Submitter

Peter Anderson

Description

5010 explanations for reversals and corrections, balance forward processing, and claim overpayment recovery are very helpful. Thank you!

Payer scenario:

• We use overpayment recovery option 1 (immediate recovery via reversal and correction)
• This causes the current 835 (835#1) to have a negative payment amount, necessitating a negative PLB/FB adjustment
• We then receive a refund check from the provider

Since we are not expecting a refund with option 1, how do we acknowledge the refund and resolve the outstanding balance forward?

We believe it would be appropriate in 835#2 to report the positive PLB/FB adjustment and a negative PLB/B2 adjustment to reflect the rebate. This would resolve the outstanding balance and reflect the refund as described in the note attached to PLB adjustment code B2. However, we would not be reporting the PLB/72 with offsetting PLB/WO (since these would be zero).

Is this your recommended approach? Is it the most provider-friendly method?

Submitter Assigned Keywords

835 PLB refund

Response

There are a couple ways to handle this situation.

1. You can return the check to the provider with an explanation that tells them you auto recover and to not send checks – this may help avoid this ongoing; or,

2, Keep the check and apply it to the balance owed. If you would like to take care of this within the 835 you would use B2 following its instructions so just a negative amount (adds the $ to the remit) of the check received with the check number as the reference ID. PLB02 = B2 with a negative dollar amount full amount of the check and PLB03-2 = Check number received.

If state regulations, business practices, and/or trading partners agree, overpayments can be recouped from claim payments within the 835.
Submission 4/8/2009
Status Date 9/14/2009
Status F - Final
Primary References
Document 005010X221
Section2.4
Page219
Set ID835
Table3
Segment Position0100
Segment IDPLB
Element Position03
Component Position1
Industry NameAdjustment Reason Code
External Code ListDE 426
Code ValueB2