Create Date 02/25/2014 Revise Date 08/04/2015 Page 1 of 5 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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
Create Date 02/25/2014 Revise Date 08/04/2015 Page 2 of 5 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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
Reference Number:
Patient Account Number + 1
stDate of Service + Claim Number
Used when:
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
Reference Number:
Patient Account Number + 1
stDate of Service + Claim Number
Used when:
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
Reference Number:
Patient Account Number + 1
stDate of Service + Claim Number
Used when:
Create Date 02/25/2014 Revise Date 08/04/2015 Page 3 of 5 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
qualifier.
Example: PLB*123456789*20141231*CS:PTACCT# CCYYMMDD CLAIM#*100~
Adjustment Code:
FB – Forwarding Balance
Reference Number:
Current Check # (TRN02) value
Used when:
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.)
Create Date 02/25/2014 Revise Date 08/04/2015 Page 4 of 5 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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
Provider number = 1234
Overpayment = 100.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02
checkA
Create Date 02/25/2014 Revise Date 08/04/2015 Page 5 of 5 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
