Medicare Advantage: Interpreting the 'PLB' Segment on the 835 Electronic Remittance Advice (ERA)

Nov. 25, 2019

The below announcement applies to providers submitting claims for the following Blue Cross and Blue Shield of Oklahoma (BCBSOK) government programs members:

  • Blue Cross Medicare Advantage (HMO)SM
  • Blue Cross Medicare Advantage (PPO)SM

Reversals and corrections may occur when claim adjudication results have been modified from a previous claim report. The method for revision is to reverse the entire claim and resend with modified data. Provider level adjustments are reported in the Provider Level Balance (PLB) segment within the 835 ERA from BCBSOK.

As of Dec. 5, 2019, the following information will change in the 835 ERA PLB segment for the above-referenced members’ claims:

  • Adjustment Reason Code (PLB03-1) — qualifier FB (Forward Balance) will be replaced with qualifier WO (Overpayment Recovery – negative amount).
  • Provider Adjustment Identifier (PLB03-2) — this field currently contains check number and will be replaced with patient control number and payer document control number (DCN) of the overpaid claim.
    • Example: PLB*15483NN082*20191231*WO:JONES001 181580099999*-1156

We encourage you to refer to the Medicare Advantage: Interpreting the 'PLB' Segment on the 835 ERA resource document on our Provider website. This document provides 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).* The document also includes information on PLB segment definitions and examples, as well as how to locate overpaid claims on the ERA and paper Provider Claim Summary (PCS).

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

 

*The HIPAA mandated ASC X12 Health Care Claim / Payment Advice (835) TR3 is available for purchase on the X12 website.

References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.