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Back  RFI # 968: 835 5010 TR3

Formal vs. Informal Help Informal Formal

Submitter

Joyce Cianciola

Description

Section 1.10.2.17 Claim Overpayment Recovery of the 835 5010 TR3, documents how to report a claim overpayment recovery using the PLB segment. The examples specifically reference re-adjudication of a claim resulting in an overpayment. The instructions for populating the PLB segment state the use of the claim internal control number in the PLB segment to identify the claim with the overpayment. The PLB segment situational rule states: "Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this impelmentaiton guide, do not send". The situational rule appears to be in conflict with the instructions in Section 1.10.2.17 for reporting an overpayment recovery of a single claim.

Submitter Assigned Keywords

835 5010 PLB Segment

Response

There is no contradiction between the sections. When the Payer's
Claim Control Number is used in the CLP segment, it is a claim reference
number. When it is used in the PLB segment as part of a claim
overpayment recovery, it is not being used as a claim reference number,
but as a receivable identification number. The reversal and correction
process completely recoups the funds from a re-adjudication that
resulted in a net overpayment. The PLB segment entry is no longer
related to the claim, but to a temporary receivable created for the
separate recovery of the overpayment funds using a delay process.
Submission 2/22/2010
Status Date 5/21/2010
Status F - Final
Primary References
Document 005010X221
Section1.10.2.1
Page48
Set ID835