| Notices and Announcments
Interpreting the PLB Segment on the 835 ERA
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 your 835 Electronic Remittance Advice (ERA) from Blue Cross and Blue Shield of Texas (BCBSTX).
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 (PLB) 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 Technical Report Type 3 (TR3).* Questions may be directed to our Electronic Commerce Center at 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 BCBSTX. If you disagree, overpayment disputes/appeals must be submitted within 90 days. 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 BCBSTX, or do nothing, in which case the payment recovery will occur automatically. If you disagree, overpayment disputes/appeals must be submitted within 90 days. 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 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.
ICD-10: Moving Toward Business As Usual
Across the industry, the move to ICD-10 appears to have been relatively smooth for most providers. Now that we have transitioned to ICD-10, our dedicated ICD-10 email help desk at icd@bcbstx.com will be discontinued as of Dec. 31, 2015.
For reference purposes, general information such as links to industry resources will remain available in the Standards and Requirements/ICD-10 section of the BCBSTX provider website. As always, if you have questions or need personalized assistance, you may contact your local Network Management Representative.
Blue Advantage HMOSM and Blue Advantage PlusSM Provider Webinar
BCBSTX Network Management Department will be holding a Dec. 10 provider webinar training session to review information regarding products offered on the Health Insurance Marketplace in 2016.
The webinar will be held from 10 a.m. to 10:50 a.m. CT. Please join us! If you have questions please call your network representative. BCBSTX Provider Relations
Office Locations | Telephone Number | Fax Number | Austin | 512-349-4847 | 512-349-4853 | Corpus Christi | 361-878-1623 | 361-852-0624 | Dallas, East Texas | 972-766-8900 /
800-749-0966 | 972-766-2231 | El Paso | 915-496-6600, press 2 | 915-496-6611
915-469-6614 | Houston, Beaumont | 713-663-1149 | 713-663-1227 | Lubbock, Amarillo | 806-783-4610 | 806-783-4666 | Midland, Abilene, San Angelo | 432-620-1406 | 432-620-1428 | San Antonio | 361-878-1623 | 361-852-0624 |
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