March 2018 

Interpreting the “PLB” Segment on the 835 ERA

There are reversals and corrections when claim adjudication results have been modified from a previous report. 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 your 835 ERA from Blue Cross and Blue Shield of New Mexico (BCBSNM).

Adjustments in the PLB segment can either decrease the payment (a positive number) or increase the payment (a negative number). The sum of all claim payments (CLP04) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (BPR02). The information in the PLB segment must be taken into consideration for auto-posting of payments to your patient accounts.

Below are additional details regarding adjustment codes that may appear in the PLB segment, in accordance with the requirements as specified within the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated Technical Report Type 3 (TR3)*. Questions may be directed to our Electronic Commerce Service Center at ecommerceservices@bcbsnm.com or 800-746-4614.

Please share this important information with your practice management software vendor, and/or your billing service or clearinghouse, if applicable.

C5 – Temporary Allowance	This code is used to inform you that we have identified an overpayment of less than $50. We recommend checking your books to confirm details. You may elect to submit a refund to BCBSNM. If you disagree, overpayment disputes/appeals must be submitted within 90 days from the date of the report. Example: PLB*15483NN082*20151231*C5:02015NNNQ3980X00.55NN30940*-2 In order to balance this scenario, the debit, credit record, along with the PLB must be processed together. The end result should be $0.
CS – Adjustment	This code is used to inform you that we have identified an overpayment of $50 or more. We recommend checking your books to confirm details. You may elect to submit a refund to BCBSNM, or do nothing, in which case the payment recovery will occur automatically. If you disagree, overpayment disputes/appeals must be submitted within 90 days from the date of the report. Example: PLB*15483NN082*20151231*CS:020150NNN0C85890X00.5NN82101*-1156 In order to balance this scenario, the debit, credit record, along with the PLB must be processed together. The end result should be $0.
WO – Overpayment Recovery	This code indicates the automatic recovery of a previous payment. Example: PLB*154837NN82*20151231*WO: 0201509NN08956B0X.5520NN142*1156*
WO – Overpayment Recovery 72 – Authorized Return B2 – Rebate	This combination is used to acknowledge the return of funds. Example: PLB*15483NN082*20151231*72: 0201509NN08956B0X.5520NN142*-14* WO: 0201509NN08956B0X.5520NN142*14*B2: 0201509NN08956B0X.5520NN142*-14

*The HIPAA mandated ASC X12 Health Care Claim/Payment Advice (835) TR3 is available for purchase on the Washington Publishing Company (WPC) website at wpc-edi.com. WPC is an independent third-party vendor that is solely responsible for its products and services.