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Formal vs. Informal Help Informal Formal


Craig Keene


This pertains to the 835 transaction. We are having difficulty determining if the guide is saying "this is mandatory functionality" or "this is the mandated method to report this data, if you choose to report it" in several areas. Currently, we are examining the reporting of payments received from a provider in response to a claim overpayment. Is the use of the 72 qualifier in PLB03-1 to acknowledge funds received from a provider (solicited and unsolicited) a HIPAA 5010 requirement, or is it strictly the required method to report this information if a plan chooses acknowledge check receipt via the 835?

Submitter Assigned Keywords

provider unsolicited refunds


This issue is explicitly addressed in guide 005010X221. Section states "... the health plan will acknowledge the receipt of the check using the PLB segment of the next 835". Therefore, if a provider is receiving an 835, then the 835 must include this business functionality when it applies in order to be consistent with the guide. The Health Plan can not determine that they choose to not provide an acknowledgement of the received check in the 835.

This response is specific to the question asked. The reference to 'other areas' in the Description is not addressed. Each 'other area' would each depend upon the specific situation and the details of the guide as related to that business.
Submission 10/22/2009
Status Date 11/11/2009
Status F - Final
Primary References
Document 005010X221
Set ID17
Segment IDPLB
Element Position03
Component Position1
Code Value72