Covered in this document: Provider Level Adjustments Adjustment Code:WO Overpayment Recovery Adjustment Code:72 Authorized Return Adjustment Code:CS Adjustment Adjustment Code:FB Forwarding Balance Complex Forward Balance Examples Create Date 02/25/2014 Revise Date 08/04/2015 Page 1 of 5
Provider Level Adjustments Provider Level Adjustments appear in the PLB segment in the 835 electronic remittance advice. The adjustments are not always associated with a claim in the same 835, but are needed to balance the 835 at the transaction (check) level. The adjustments will increase the payment when a negative money amount is returned, or decrease the payment when a positive money amount is returned. The following information pertains to the content returned in the PLB for Overpayment and Recovery processes. Further details for these and other PLB qualifiers and their usage may be found in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3). Adjustment Code Reference ID Adjustment Code:WO Overpayment Recovery A corrected and reversed claim record appears in the 835 and the monies are not immediately recovered, the PLB with a WO will be present with a negative money value. These monies will be recovered in a future 835. A previous overpayment is recovered. Monies will be expressed as a positive value. Acknowledging a refund sent by the provider for an overpayment notification. The WO with a positive money value will be offset by a 72 with a negative money value. Example: PLB*123456789*20141231*WO:PTACCT#CCYYMMDD CLAIM#*-37.5~ Adjustment Code:72 Authorized Return Acknowledging a refund sent by the provider for an overpayment notification. The WO with a positive money value will be offset by a 72 with a negative money value. Example: PLB*123456789*20141231*WO:PTACCT#CCYYMMDD CLAIM#*25*72:PTACCT#CCYYMMDD CLAIM#*-25~ Adjustment Code:CS - Adjustment A refund received from a provider triggers a previously paid claim to adjust. A corrected and reversed claim record appears in the 835 and the refunded monies appear as a positive money value in the PLB with a CS Create Date 02/25/2014 Revise Date 08/04/2015 Page 2 of 5
qualifier. Example: PLB*123456789*20141231*CS:PTACCT# CCYYMMDD CLAIM#*100~ Adjustment Code:FB Forwarding Balance Reference Number:Current Check # (TRN02) value An overpayment can t be recovered in full resulting in a forwarding balance to be recovered from a future payment. An existing forwarding balance can t be recovered in full resulting in a new forwarding balance. The TRN02 values will be as defined in the X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3). Example: PLB*123456789*20141231*FB:Check#*-37.5~ Complex Forward Balance Examples 835 Electronic Remittance Advice PLB Segment: TheASC X12 Standards for Electronic Data Interchange Technical Report Type 3 has specific rules for reporting overpayment recovery in the 835. The following information should be referenced to understand the formatting of the PLB segments of the 835 for recoupment of funds and when forward balance situations occur. The following applies in situations where the recoupment will occur at the time a reversed and corrected claim record populates the 835. When the adjustment is less than the original paid amount, the difference will be subtracted from the check. When the monies can t be recovered in full, a forwarding balance (FB) is created in the PLB segment. Per the guide, the FB reference ID must be the current TRN02 (check number) value. The monies unable to be recovered will be identified as a forwarding balance (FB) with the monies expressed as a negative. PLB*9999999999*20141231*FB TRN02CheckA*-100 When the monies can be recovered from future payment, the forwarding balance (FB) will be returned with the monies expressed as a positive. (To identify what claims are associated to the PLB where TRN02CheckA is referenced, refer back to the original 835 where TRN02CheckA first occurred.) PLB*9999999999*20141231*FB TRN02CheckA*100 Create Date 02/25/2014 Revise Date 08/04/2015 Page 3 of 5
If forwarding balance (FB) monies are unable to be recovered in full, a new forwarding balance (FB) will be created with the new balance. (To identify what claims are associated to the PLB where TRN02CheckA and TRN02CheckB arereferenced, refer back to the original 835 where TRN02CheckA first occurred. PLB*9999999999*20141231*FB TRN02CheckA*100 PLB*9999999999*20141231*FB TRN02CheckB*-50 Additional Complex Forward Balance Examples Multiple days where claims were adjusted and negative balances occurred in different 835 ERA s Day 1: Check A The provider had previously received an 835 with a correction and reversal where the amount owed was $100. The remit that generated the reversal and correction only had funds available with the check to satisfy $62.50. The FB generated in that remit was for -37.50. A subsequent remit is now being generated and now $37.50 can be used to satisfy the forward balance left in full. Day 2: Check B The provider had previously received an 835 with a correction and reversal where the amount owed was $200. The remit that generated the reversal and correction only had funds available with the check to satisfy $75.00. The FB generated in that remit was for -125.00. A subsequent remit is now being generated and now $125.00 can be used to satisfy the forward balance left in full. Day 3: Check C The provider had previously received an 835 with a correction and reversal where the amount owed was $300. The remit that generated the reversal and correction only had no funds available to satisfy $300.00. The FB generated in that remit was for -300.00. A subsequent remit is now being generated and now $200 can be used to satisfy and will create a new FB for -100.00 First initial Remittance where FB occurred: Day1: Check A Overpayment = 100.00 TRN02 value - TRN02checkA Create Date 02/25/2014 Revise Date 08/04/2015 Page 4 of 5
Reversal and correction claim And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKA*-37.5~ Day 2: Check B Overpayment = 200.00 TRN02 value - TRN02checkB Reversal and correction claim And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKB*-125.00~ Day 3: Check C Overpayment = 300.00 TRN02 value - TRN02checkC Reversal and correction claim And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKC*-300.00~ DAY 4: Check D Second subsequent remittance (different day/check/eft): TRN02 value TRN02checkD Balance yet to be satisfied is $37.50, 125.00 and 300.00 = 462.50 The remittance only has sufficient funds to offset $237.50 (CheckA 37.50 and Check B 125.00 and check C 200.00) with balance left of 100.00 The remittance would ONLY have the following: PLB*1234*20011231*FB: TRN02CHECKA*37.50*~ PLB*1234*20011231*FB: TRN02CHECKB*125*~ PLB*1234*20011231*FB: TRN02CHECKC*300*FB: TRN02CHECKD*-100~ Create Date 02/25/2014 Revise Date 08/04/2015 Page 5 of 5