| December 3, 2015 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 (PLB) are reported in the PLB segment within your 835 Electronic Remittance Advice (ERA) from Blue Cross and Blue Shield of Oklahoma (BCBSOK). 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 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 BCBSOK. 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 and 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 BCBSOK, 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. |
