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Recoupments are identified with the plb reason code wo Palmetto gba sends an overpayment demand letter for each overpayment eligible for 935 appeal rights. Clarification of the plb reason codes fb and wo are below
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A forwarding balance is not a recoupment This module gives you the basics of provider level balance (plb) reason codes and helps you reconcile your medicare remittance advices (ras) It is notifying the provider the claim has already paid previously
The claim may have previously paid more, less, or the same.
If you're having trouble locating a recoupment, try searching the era file for keywords like “plb” or reason codes such as wo (overpayment recovery) These adjustments are typically listed after the last processed claim in the era file. The plb is not always associated with a specific claim in the 835 but must be used to balance the transaction Use the reference id to identify the claim.
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. Interpreting the ‘plb’ segment on the 835 electronic remittance advice (era) there are reversals and corrections when claim adjudication results have been modified from a previous claim report The method for revision is to reverse the entire claim and resend the modified data. Instructions for plb code reporting on remittance advice and a crosswalk between the higlas plb codes and asc x12 transaction 835 plb codes, and rac recoupment reporting on remittance advice for vms.
On the electronic remittance advice (era), a code of oa is used for part a affiliated withholdings and a code of ob is used for part b affiliated withholdings.
Ra has to report the actual recoupment in two steps when there is a time lag between reversal/correction process when overpayment is identified and when medicare actually recoups the money. The centers for medicare & medicaid services (cms) prepared this remittance advice (ra) booklet for medicare providers to access ra information This booklet contains information about ras and allows different provider types to navigate easily to relevant topics.
