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ANSI v5010 Update: Interpreting the PLB Segment on the 835 ERA

July 18, 2012

 

You may have noticed changes on your electronic remittance advice (ERA) from Blue Cross and Blue Shield of New Mexico (BCBSNM), as a result of new ANSI Version 5010A1 835 requirements specified in the Technical Report Type 3 (TR3). As a reminder, the TR3 is available for purchase on the Washington Publishing Company (WPC) website at wpc-edi.com.

There are reversals and corrections when claim adjudication results have been modified from a previous reporting. The method for revision is to reverse the entire claim and resend the modified data. Provider level adjustments are reported in the PLB segment within the ERA.

Adjustments in the PLB segment can either decrease the payment (a positive number) or increase the payment (a negative number). You should alert your practice management software vendor, as the information in the PLB segment must be taken into consideration for auto-posting of payments to your patient accounts.

INFORMATION FOR YOUR VENDOR

Included below are additional details regarding the adjustment codes you may see in the PLB segment, in accordance with the TR3. Please share this important information with your practice management software vendor, and/or your billing service or clearinghouse, if applicable. Questions may be directed to our Electronic Commerce Center at 800-746-4614.

WO – Overpayment Recovery

This is the recovery of a previous payment. An identifying number must be provided in PLB03-02. (See notes on codes 72 and B2 for additional information about balancing against a provider refund.)

Example:

PLB*154837NN82*20121231*WO:0201209NN08956B0X.5520NN142*1156*

72 – Authorized Return

This is the provider refund adjustment, acknowledging a refund received from a provider for a previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment. Referring to the original refund request or reason for balancing purposes, the amount related to this adjustment reason code must be directly offset.

B2 –

Rebate

This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 and offset by the amount with code WO. The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider.

Example:

PLB*154837NN82*20121231*72:020120NN5076B180X00.5520NN794*-9281.11*WO:020120NN5076B180X00.5520NN794*9281.11*B2:020120NN5076B180X00.5520NN794*-9281.11

CS – Adjustment

Provide supporting identification in PLB03-2.

Example:

PLB*15483NN082*20121231*CS:020120NNN0C85890X00.55NN82101*-1156

C5 – Temporary Allowance

This is a tentative adjustment used to convey to the provider information for debit or credit transactions. This is used in situations where there is a reduction in payment under $50.

Example:

PLB*15483NN082*20121231*C5:02012NNNQ3980X00.55NN30940*-2

 

Balancing Procedure

The amounts reported in the 835, if present, must balance at three different levels, as follows:

  1. Service Line – Record the BPR02 (the total actual payment to the provider for this 835). This is the check or Electronic Funds Transfer (EFT) amount.
  2. Claim Level – Sum the CLP04 (Claim Payment Amount).
  3. Transaction Level – Summarize any PLB adjustments, if any, and reverse the sign of the value.

The sum of all claim payments (CLP04) minus the sum of all provider level adjustments (PLB) equals the total payment (BPR02).


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