Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 812 Date: November 12, 2010

Transcription

1 anual ystem Pub One-Time Notification Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 812 Date: November 12, 2010 hange equest 7068 UBJET: nstructions for PLB ode eporting on emittance Advice and a rosswalk Between the GLA PLB odes and A X12 Transaction 835 PLB odes, and A ecoupment eporting on emittance Advice for V.. UAY O ANGE: This instructs the hared ystem aintainers about using and reporting PLB codes on the emittance Advice (A). t also provides a crosswalk between the GLA PLB codes and the A X12 Transaction 835 PLB codes to ensure that PLB code reporting on the A is consistent and uniform across the board. t also includes instruction for V how to report A recoupment when there is a time difference between the creation of the Accounts eceivable and actual recoupment of money. EETVE DATE: April 1, 2011 PLEENTATON DATE: April 4, 2011 for July 5, 2011 for and V Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged.. ANGE N ANUAL NTUTON: (N/A if manual is not updated) =EVED, N=NEW, D=DELETED /N/D APTE / ETON / UBETON / TTLE N/A. UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; ontractor activities are to be carried out within their operating budgets. or edicare Administrative ontractors (As): The edicare Administrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the A tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. V. ATTAENT: One-Time Notification *Unless otherwise specified, the effective date is the date of service.

2 Attachment One-Time Notification Pub Transmittal: 812 Date: November 12, 2010 hange equest: 7068 UBJET: nstructions for PLB ode eporting on emittance Advice and a rosswalk Between the GLA PLB odes and A X12 Transaction 835 PLB odes, and A ecoupment eporting on emittance Advice for V. Effective Date: April 1, 2011 mplementation Date: April 4, 2011 for July 5, 2011 for and V. GENEAL NOATON A. Background: PLB code reporting: The emittance Advice (A) reports payments and adjustments to payments at 3 levels: a) service b) claim c) provider The adjustments at the service and the claim level are reported using 3 sets of codes Group odes, laim Adjustment eason odes (As) and emittance Advice emark odes (As). Provider level adjustments are reported using the PLB codes. The PLB code list is an internal code list that can be changed only when there is a change in the version. n version A1, the following PLB codes are available for use: 50, 51, 72, 90, A, AP, B2, B3, BD, BN, 5,,, T, V, W, D, E3, B,, GO, P,,, J1, L3, L6, LE, L, OA, OB, P, PL, A, E, L, TL, WO, WU, AND ZZ. n version A1, two new codes A and have been added, and code ZZ has been deleted. The other change in version A1 is the way situational field PLB03-2 for reference identification is used. ield Version A1 Version A1 PLB03-1 A additional code additional code ZZ deleted code PLB03-2 ax: 30 ax: 50 equired when a control, account or tracking number applies to this adjustment as reported in field PLB03-1 Position 1-2: edicare intermediaries must enter the applicable edicare code No edicare specific codes Position 3-19: inancial control identify/track/reconcile the provider level adjustment Number or other pertinent identifier Position 20-30: ealth nsurance laim () Number

3 This instructs the hared ystem aintainers (s) about using and reporting PLB codes on the emittance Advice (A). t also provides a crosswalk between the GLA PLB codes and the A X12 Transaction 835 PLB codes to ensure that PLB code reporting on the A is consistent and uniform across the board. GLA uses additional PLB codes from the X12 tandard that are not in the mplementation Guide (G) or Technical eport (T) 3. edicare must use only those codes that are included in the G/T3 to report on the 835. urrently is in the process of transitioning to GLA, and some contractors are still not under GLA. This applies to both GLA and Non-GLA contractors with the goal of uniform and consistent reporting on the 835 across the board. econdly, is also in the process of implementing the new version adopted as the ealth nsurance Portability and Accountability Act (PAA) standard - version 5010A1. Attachment 835 PLB ode apping is applicable to version A1 as well as 5010A1. A recoupment reporting V only: n the Tax elief and ealth are Act of 2006, ongress required a permanent and national ecovery Audit ontractors (A) program to be in place by January 1, The goal of the recovery audit program is to identify improper payments made on claims of health care services provided to edicare beneficiaries. The As review claims on a post-payment basis, and can go back 3 years from the date the claim was paid. To minimize provider burden, the maximum look back date is October 1, ection 935 of the edicare Prescription Drug, mprovement, and odernization Act of 2003 (A) (Publication. L ) amended Title XV of the ocial ecurity Act (the Act) has added a new paragraph (f) to 1893 of the Act, the edicare ntegrity Program. The statute requires edicare to change how certain overpayments are recouped. These new changes to recoupment and interest are tied to the edicare fee-for-service claims appeal process and structure. ecoupment under the provisions of 935 of the A can begin no earlier than the 41st day (see hange equest () 6183 Transmittal 141, issued eptember 12, 2008), and can happen only when a valid request for a redetermination has not been received within that period of time. Under the scenario just described, the A has to report the actual recoupment in two steps: tep : tep : eversal and orrection to report the new payment and negate the original payment (actual recoupment of money does not happen here) eport the actual recoupment n a previous (Transmittal 659, 6870), iscal ntermediary tandard ystem and ulti arrier ystem have been instructed to provide enough detail in the A to enable providers to track and update their records to reconcile edicare payments. The ront atter laim Overpayment ecovery in A X12N/005010X221 provides a step-by-step process regarding how to report in the A when funds are not recouped immediately, and a manual reporting (demand letter) is also done. This instructs VPs edicare ystem (V) how to report on the A when an overpayment is identified and also when edicare actually recoups the overpayment in a future A. tep : laim Level: The original claim payment is taken back and the new payment is established (eversal and orrection) Provider Level: PLB03-1 PLB reason code B (orward Balance) PLB 03-2 shows the detail: PLB : : Adjustment N#

4 20-30: # PLB04 shows the adjustment amount to offset the net adjustment amount shown at the service level. f the service level net adjustment amount is positive, the PLB amount would be negative and vice versa. tep : laim Level: No additional information at this step Provider Level: PLB03-1 PLB reason code WO (Overpayment ecovery) PLB 03-2 shows the detail: PLB : : Adjustment N# 20-30: # PLB04 shows the actual amount being recouped A demand letter is also sent to the provider when the Accounts eceivable (A/) is created tep. This document contains a control number for tracking purpose that is also reported on the A. in conjunction with the hared ystem aintainers and the A/B edicare Administrative ontractors has decided to follow the same reporting protocol for all other recoupments in addition to the 935 A recoupment mentioned above. NOTE : nstructions regarding recoupment in this apply to both A1 and 5010A1 versions of A X12 Transaction 835, and tandard Paper emittance (P). NOTE : n some very special cases the # may have to be truncated to be compliant with the A1 mplementation Guide. B. Policy: generates ealth nsurance Portability and Accountability Act (PAA) compliant remittance advice that includes enough information for providers so that manual intervention is not needed on a regular basis. edicare contractors must follow the X12N 835 G/T3 to generate the PAA compliant EA, and P must mirror the EA barring a few exceptions. Ps may not provide additional or more detailed information that a compliant EA using the PLB codes in the G/T3 cannot provide. BUNE EQUEENT TABLE Number equirement esponsibility A D / B E , and V shall make necessary programming changes to crosswalk the GLA PLB codes to the corresponding standard PLB codes included in the A X12 N A1 and A X X221A1 835 A A A E hared- ystem aintainers V X X X W Other

5 Number equirement esponsibility A D / B E G/T3 per Attachment to populate PLB03-1. A A A E hared- ystem aintainers V W Other Note: V will transition to GLA in the future, and shall implement B and/or B as applicable during the transition. Once the transition is complete, B shall apply to V ,, and V shall report adjustments populating PLB03-1 using PLB codes as listed in the Attachment with this when the GLA PLB codes are not applicable. (or contractors not under GLA at the time) ,, and V shall use PLB codes as listed in the Attachment to populate PLB03-1 for version A1 as well as version A1 of Transaction 835 X X X X X X and V shall use PLB codes as listed in the Attachment to report on the P. X X , and V shall make no change in populating PLB03-2 for version A , and V shall populate PLB03-2 for version 5010A1A1 with same data as in 4010A1 with the following updates: X X X X X X 1) and V shall no longer populate positions 1-2 with 00; 2) shall no longer populate positions 1-2 with the edicare A specific codes that are not available for version A1; 3),, and V shall populate positions 1-28 with same data that is currently being reported in positions 3-30 in 835 version A1; and 4), and V shall populate positions with additional data as instructed by V shall follow the eversal and orrection process as outlined in A X12N/005010X221A1 when overpayment is identified and an A/ is created showing what providers owe to edicare. This applies to both A1 and 5010A1A1 versions of 835, and P. X

6 Number equirement esponsibility A D / B E Note: ee tep in the Background section. A A A E hared- ystem aintainers V W Other or 935 A ecoupment V shall include the detail information as per tep above in the PLB segment to provide detail information as well as offsetting the recoupment created at the claim level so the net impact on payment would be zero or 935 A ecoupment V shall provide the same detail information at the PLB segment as per tep above when the actual recoupment happens. X X NOTE: There is no claim level reporting at tep so that the net impact on payment would be a reduction by the recoupment amount reported in the PLB segment or non-935 A ecoupment V shall include the detail information as per tep above in the PLB segment to provide detail information as well as offsetting the recoupment created at the claim level so the net impact on payment would be zero or non-935 A ecoupment V shall provide the same detail information at the PLB segment as per tep above when the actual recoupment happens if there is a time gap between the reversal/correction and the actual recoupment process... X X Note: There is no claim level reporting at tep so that the net impact on payment would be a reduction by the recoupment amount reported in the PLB segment.

7 . POVDE EDUATON TABLE Number equirement esponsibility A / D B E A provider education article related to this instruction will be available at shortly after the is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in your next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. A A A E X X X X X hared- ystem aintainers V W Other ED V. UPPOTNG NOATON ection A: ecommendations and supporting information associated with listed requirements: N/A X-ef equirement Number ecommendations or other supporting information: ection B: All other recommendations and supporting information: N/A V. ONTAT Pre-mplementation ontact(s): umita en at sumita.sen@cms.hhs.gov or Post-mplementation ontact(s): umita en at sumita.sen@cms.hhs.gov or

8 V. UNDNG ection A: or iscal ntermediaries (s), egional ome ealth ntermediaries (s): No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: or edicare Administrative ontractors (As): The edicare Administrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the A tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. Attachment: PLB ODE TO EPOT ON TE 835 AND GLA and PAA PLB ODE OWALK or alternate format, please contact the author

9 Attachment or alternate format, please contact the author PLB ODE TO EPOT ON TE 835 and GLA AND PAA PLB ODE OWALK GLA PLB X-01 code ode eaning - GLA ardcopy remit field urrent 835 PLB urrent 835 PLB ode urrent V 835 PLB ode s for 835 v40101 and v5 A X PLB ode Description omments 1 D1 ull old - Unfiled ost eport Late harge Late iling of ost eport 2 1 anual nvoices - efunds efunds 72 B2 72 Authorized return efunds - anual nvoices 3 D5 4 NA 5 NB 6 N ull old - DN L3 _ A not created anual Non laim nvoices - Positive _ nternal Use Only Distribution anual Non laim nvoices - Negative _ nternal Use Only Distribution anual Non laim nvoices - Positive _ nternal Use Only anual Non laim nvoices - Negative _ nternal Use Only 7 ND 8 A anual nvoices - Accelerated/Advance P t 9 AG PP Bad Debt PT 10 A non-pp Bad Debt PT Accelerated payments AP B2 AP Bad Debt Bad Debt BD BD BD BD Acceleration of Benefits Bad Debt Adjustment Bad Debt Adjustment anual nvoices - Accelerated/Advance Payment PP Bad Debt Adjustmment Non-PP Bad Debt Adjustment 11 BN E Bonus BN BN Bonus Demonstration Project ( 6603) 12 B PA E3 B2 BN Bonus PA Bonus 13 AQ non-pp N PT ettlement Payments anual nvoices - ost ettlement eport anual nvoices - nsurance ompanies payments: ettlement 5 ettlement Payments 5 B anual nvoices - Other ettlement Payments 5 B L anual nvoices - nterim ate eview ettlement Payments Non-PP N ettlement Payments ost eport ettlement anual nvoices anual nvoices nterim ate eview odes assigned to report ederally mandated recoupment/bonus payment: LE TL WU 1

10 Attachment or alternate format, please contact the author PLB ODE TO EPOT ON TE 835 and GLA AND PAA PLB ODE OWALK GLA PLB X-01 code ode eaning - GLA ardcopy remit field urrent 835 PLB urrent 835 PLB ode urrent V 835 PLB ode s for 835 v40101 and v5 A X PLB ode Description omments 18 N anual nvoices - PT ettlement Payments TD anual nvoices - Tentative ettlement ettlement Payments W Void - eissue plit Pay ettlement Payments L2 TPP - Garnishments Tentative ettlement eissue plit Pay WU WO Adjustment PW Garnishments 22 L4 TPP - hild upport 23 L5 TPP - Alimony 24 L6 25 L7 TPP - econdary orporation TPP - hange of Ownership WU WO Adjustment PW hild upport WU WO Adjustment PW Alimony WU WO Adjustment PW econdary orporation WU WO Adjustment hange of Ownership 26 V Voids - eissue nvoices Void/reissue Adjustment eissued nvoice 27 VD 28 VO Voids - eissue Debit emo Void - eissue nterest nformation 29 AA PP AP PT 30 AB non-pp AP PT 31 A PP DE PT 32 AD non-pp DE PT 33 AW Affiliate Withholdings Void/reissue WO Adjustment eissued Debit emo Void/reissue Adjustment eissued nterest apital apital Direct edical Direct edical payments: laims Accounts eceivable V V D D V V D D apital Passthrough apital Passthrough Direct edical Education Direct edical Education PP apital Passthrough non-pp apital Passthrough PP Direct edical Education non-pp Direct edical Education E3 E3 Withholding Affiliate Withholding 34 D Debit emo payments: ettlement L3 WO E3 Withholding Withholding per Debit emo odes assigned to report ederally mandated recoupment/bonus payment: LE TL WU 2

11 Attachment or alternate format, please contact the author PLB ODE TO EPOT ON TE 835 and GLA AND PAA PLB ODE OWALK GLA PLB X-01 code ode eaning - GLA ardcopy remit field urrent 835 PLB urrent 835 PLB ode urrent V 835 PLB ode s for 835 v40101 and v5 A X PLB ode Description omments 35 W ettlement Withholding payments: ettlement L3 E3 Withholding ettlement Withholding ross eference Netting 935 Withholding WO B/WO Withholding ollow for using B and WO at step and tep elationship Netting 935 Withholding WO B/WO Withholding ettlement ross eference Netting 935 Withholding WO B/WO Withholding ollow for using B and WO at step and tep ollow for using B and WO at step and tep ettlement elationship Netting 935 Withholding WO B/WO Withholding ollow for using B and WO at step and tep 40 TPP - Levy 41 L1 TPP - Backup WO WO 42 TL TOP ettlement Payments nternal evenue ervice nternal evenue ervice nterim ettlement 43 V onverted nvoices Penalty release L3 _ L3 Penalty P onversion 44 D2 ull old - Unfiled D3 46 D4 ull old - ejected ost eport ull old - ailure to comply Auditors L3 L3 Penalty PW Unfiled 838 L3 L3 Penalty PWejected ost eport L3 L3 Penalty PW ailure to comply Auditors 47 D6 ull old - raud and Abuse L3 WO L3 Penalty PWraud and Abuse 48 D7 ull old - Other/isc 49 D8 ull old - AP ystem old 50 D9 ull old - Terminated L3 WO L3 Penalty PW Other/isc L3 WO L3 Penalty PWAP old L3 _ L3 Penalty PWTerminated 51 D DN old elease Penalty release L3 L3 Penalty P DN odes assigned to report ederally mandated recoupment/bonus payment: LE TL WU 3

12 Attachment or alternate format, please contact the author PLB ODE TO EPOT ON TE 835 and GLA AND PAA PLB ODE OWALK GLA PLB X-01 code ode eaning - GLA ardcopy remit field urrent 835 PLB urrent 835 PLB ode urrent V 835 PLB ode s for 835 v40101 and v5 A X PLB ode Description omments 52 A ull old - Administrative reeze 53 B ull old - Bankruptcy 54 ull old - equest L3 WO L3 Penalty PW Administrative reeze L3 WO L3 Penalty PW Bankruptcy L3 WO L3 Penalty PW equest 55 ull old elease Penalty release L3 B2 L3 Penalty P 56 G2 Partial old - equest 57 G3 Partial old - Bankruptcy 58 G4 Partial old - Unfiled ost eport 59 G5 Partial old - Unfiled PA anual nvoices - Penalty elease Partial old - Admin reeze 62 PO Partial old - Other/isc L3 WO L3 Penalty PW equest L3 WO L3 Penalty PWBankruptcy L3 L3 Penalty PWUnfiled ost eport L3 L3 Penalty Unfiled 838 (redit Balance eport) Penalty release L3 B2 L3 Penalty P Penalty elease L3 WO L3 Penalty PW Administrative reeze L3 WO L3 Penalty PW Other/isc 63 P Partial old - elease Penalty release L3 B2 L3 Penalty P Penalty elease 64 L Lump um Bonus Payment for the LE LE Levy PQ Bonus Payment 65 WU ederal Payment Levy Program - payments: ederal Payment Levy WU WU LE Levy 1) TEAUY TAX WTOLD Treasury telephone xxx-xxx-xxxx 2) Any other ederally mandated payment/recoupment 66 AL PP non-pys Anest PT Non Physician Anesthetists L L Lump um PP Non-Physician Anesthetists 67 A non-pp non-phy Anest PT Non Physician Anesthetists L L Lump um non-pp Non-Physician Anesthetists 68 AE PP Kidney PT Kidney Acquisition OA OA Organ Acquisition PP Kidney odes assigned to report ederally mandated recoupment/bonus payment: LE TL WU 4

13 Attachment or alternate format, please contact the author PLB ODE TO EPOT ON TE 835 and GLA AND PAA PLB ODE OWALK GLA PLB X-01 code ode eaning - GLA ardcopy remit field urrent 835 PLB urrent 835 PLB ode urrent V 835 PLB ode s for 835 v40101 and v5 A X PLB ode Description omments 69 A non-pp Kidney PT 70 A Affiliate Withholdings - ettlement Kidney Acquisition payments: Affiliated 71 AP PP N PT PP Payments P P 72 anual nvoices - PP PP Payment P P 73 PP PP PP Payment P P OA OB OA OB Organ Acquisition Offset for Affiliated Periodic nterim Payment Periodic nterim Payment Periodic nterim Payment non-pp Kidney 74 PL anual 935 nvoice 935 Payments PL B2 PL Payment inal anual 935 nvoice 75 AN PP OE PT 76 AO non-pp OE PT 77 L TPP - tudent Loan eturn on Equity eturn on Equity E E eturn on Equity PP O E E eturn on Equity non-pp O L WO L 78 2 TE ecoupment TL 79 L8 Accelerated/Advance ecoupments payments: Accellerated AP WO WO tudent Loan epayment Third Party Liability Overpayment ecovery TE ecoupment T XXXX Phone # XXX-XXX-XXXX Advance ecoupment Application 80 WO A/AP Netting Offset payments: laims Accounts eceivable E3 WO WO Overpayment ecovery A/AP Netting 81 ZZ ederal Payment Levy Program - non-tax payments: Non-tax PLP ZZ ZZ WU 1) TEAUY NON-TAX WTOLD Treasury telephone xxx-xxx-xxxx 2) Any other ederally mandated payment/recoupment NON-GLA UE 82 AP AP Acceleration of Benefits Advance Payment odes assigned to report ederally mandated recoupment/bonus payment: LE TL WU 5

14 Attachment or alternate format, please contact the author PLB ODE TO EPOT ON TE 835 and GLA AND PAA PLB ODE OWALK GLA PLB X-01 code ode eaning - GLA ardcopy remit field urrent 835 PLB urrent 835 PLB ode urrent V 835 PLB ode s for 835 v40101 and v5 A X PLB ode Description omments 83 _ orrection and eversal at the claim/line level 84 B B orward Balance Over Payment 85 B/WO Withholding ollow for using B and WO at step and tep for 935 ecoupment J1 J1 nternal evenue ervice Nonreimbursable Adjustment per Demonstration Project 88 AP AP Acceleration of Benefits Payment to withheld because it has been determined that the provider/supplier is on Do Not orward (DN) or investigated for fraud. 89 L6 L6 L6 nterest Owed nterest paid on claims in this WO WO ADD-ON-PAYENT Overpayment ecovery A/AP Netting 91 Outlier 82 / emo. is a new code available in New Technology 94 L L ndirect edical Education odes assigned to report ederally mandated recoupment/bonus payment: LE TL WU 6