Forward balance and withholding

FB Forwarding Balance

A negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous RA. A reference number (the original ICN and HIC) is applied for tracking purposes. Code "BF" appears on an Institutional RA for negative values (e.g., FB/BF), and code "CO" for positive values (e.g., FB/CO).


E3 Withholding


Used to reflect a withholding of a set dollar amount or a percentage of a capitation payment, to be paid later, usually as a result of meeting performance requirements. Code "CW" appears on an Institutional RA (e.g., E3/CW).


Provider-Level Adjustment Codes

Provider-Level Adjustment (PLB) reason codes describe adjustments the Medicare Contractor makes at the provider level, instead of a specific claim or service line. Some examples of provider-level adjustments include:

• An increase in payment for interest due as a result of late payment of a claim by Medicare
• A deduction from payment as a result of prior overpayment, and
• An increase in payment for any provider incentive plan Basics
• Provider-level adjustments can increase or decrease the transaction payment amount.
• Adjustment codes are located in PLB03-1, PLB05-1, PLB07-1, PLB09-1, PLB11-1 and PLB13-1 segments.
• The PLB is not always associated with a specific claim in the 835 (Health Care Claim Payment/Advice), but must be used to balance the transaction.
• Use the Reference ID to identify the claim. Exceptions are the FB, IR, J1, L6 and CS adjustment codes (when used for provider write-off only).
• Use the dollar amount in the PLB to balance the 835 transaction.

Types of Activity Reported via the PLB Segment

• Interest Payments

• Refund Acknowledgements

• Overpayment Recoveries

• Forwarding Balances for FUTURE Overpayment Recovery

• Pass Through and Settlement Payments

Most Commonly Used 835 Adjustment Codes

• Forward Balance (FB)

• Overpayment recovery (WO)

• Authorized Return (72)

• Internal Revenue Service Withholding (IR)

• Non-Reimbursable (J1)

• Interest Owed (L6)

• Adjustment (CS)

Forward Balance (FB) Adjustment Code Reference ID Forward Balance (FB)

Used to reflect a balance being moved forward to a future remit or a balance that is brought forward from a prior Medicare Remittance Advice (RA).

• When a balance is moving forward to a future RA, the PLB FB contains the check or Electronic Funds Transfer (EFT) trace number from the current 835 transaction.

• When a balance has been brought forward from a prior remit, the PLB FB contains the check or EFT trace number that was Reference ID in the prior RA. 

Posting Tips:

• A negative value represents a balance moving forward to a future payment advice.

• A positive value represents a balance being applied from a previous advice.

• The PLB FB is used to move a negative balance from a current 835 transaction into a future 835 transaction (Typically, this happens when CGS reports an overpayment and there are not sufficient funds to recoup the entire overpayment amount.)


Overpayment Recovery (WO)

• Used when a previous overpayment is recouped from the provider of service.

• Used when a reversal and corrected claim are not reported in the same transaction.

WO prevents the prior claim payment from being deducted from the transaction.

• Used to offset the PLB 72.

• Used when a reversal and corrected claim are reported and the overpayment is not immediately recouped. WO prevents the prior claim payment from being deducted from the transaction.

• The Reference ID for the PLB WO contains the beginning date of service from the claim and the patient account number.

• When reporting a voided check, the Reference ID in the PLB WO is the voided check number.



Posting Tips:

• Provider refund check reporting — When CGS receives a provider’s refund check, the amount of the check is reported as a positive value in the PLB WO and a negative value in the PLB 72.

• Voided checks — When a check is voided, the amount of the check is reported as a positive value in the PLB WO and a negative value in the PLB 72. The Reference ID in the PLB WO will contain the voided check number.

• Overpayment Reduction — When a claim overpayment is identified, CGS reports a reversal to the original claim and a corrected claim if there are sufficient funds from other claim payments to recover the amount of the overpayment. If sufficient funds are not available, after 60 days CGS handles the overpayment by sending a demand letter to demand payment for the balance of the overpayment.

• Overpayment Recovery Reduction — Used when a previous overpayment is recouped from the provider of service. CGS sends a letter requesting a refund. If the refund is not received within the requested timeframe, CGS recoups the money. The overpayment reduction is reported as a positive value in the PLB WO.


Authorized Return (72) Adjustment Code Reference ID Authorized Return (72)

• Used to report the dollar amount returned by the provider of service for a previous overpayment. 

• Used to report a voided check. 

• The Reference ID in the PLB 72 contains the beginning date of service from the claim and the patient account number

• When reporting a voided check, the Reference ID in the PLB 72 is the voided check number.

Posting Tips:

• When CGS receives a refund, CGS notes the refund amount as a negative value in the PLB segment with the 72 Adjustment Reason Code.

• When a provider returns a CGS check, the voided check amount is noted as a negative value in the PLB 72. The Reference ID in the PLB 72 will contain the voided check number.

• A PLB WO with the amount of the refund or voided check is reported as a positive value to offset the PLB 72 and balances the 835 transaction.

For Solicited Refunds:

• The reversal and corrected claim were reported in a prior 83 and included a PLB WO so that overpayment funds weren’t recouped.

• Once the refund is received by CGS, the refund amount is noted as a negative value in the PLB segment with the 72 Adjustment Reason Code.

• A PLB WO with the amount of the refund is then created to offset the PLB 72 and balance the 835 transaction. The PLB WO will contain a positive value. 

For Unsolicited Refunds:

• When CGS posts a refund, we enter both a reversal of payment and a corrected claim so that the reversal and PLB 72 will be in the same 835 file.

• If the refund does not cover the entire overpayment amount, the 835 will also contain a PLB WO for the amount remaining to be refunded. The PLB WO will contain a negative value. 



Internal Revenue Service Withholding (IR)

• Used for IRS tax withholding.

• The Reference ID in the PLB IR contains the comment “IRS Withhold for TIN XXXXXXXXX” Posting Tips:

• The payment amount sent to the IRS is reported in the PLB segment with an IR Adjustment Reason Code and a positive
dollar amount.

• The claim will be in the same 835 as the PLB. Post the claim payment amount(s) to your patient accounts, but note that you will not physically receive funds for the payment amounts.

Non-Reimbursable (J1)

Adjustment Code Reference ID

Non-Reimbursable (J1)

Used when the service provider is also the employer group and they request that monies be applied towards the Group Medical Plan coverage premium instead of the claim.

The Reference ID in the PLB J1 contains the comment “Suppressed Payment Arrangement.”

Posting Tips:

• J1 will be in the same 835 as the claim.

• Post amounts to your patient accounts, but note that you will not physically receive funds for the claim payments.

• The dollar amount of the suppressed payment for the PLB J1 will be a positive value.

Interest Owed (L6)

Adjustment Code Reference ID

Interest Owed (L6)

Used to report interest paid on claim.

No Reference ID is included with the PLB L6. The amount reported is a sum of the AMT*1 segments.

Posting Tips:

• The amount of interest paid is reported in the PLB L6 as a negative amount and adds to the check total. The claim is in the same 835 transaction.

• To associate interest amounts with corresponding claims, use the AMT*1 segments at the claim level.

• The claim will contain an AMT segment in loop 2100 with an “I” (Interest) Amount Qualifier Code in the AMT01 and the interest amount in the AMT02.

Adjustment (CS)

Adjustment Code Reference ID

Adjustment (CS)

• Used to report the reissued payment amount for a lost check, or to

• Reduce a PLB FB balance if CGS writes off an amount a provider owes. When reporting repayment for a lost check, the Reference ID contains the check number of the lost check.

Posting Tips:

• The amount of the lost check is reported in the PLB CS as a negative value.

• The claim associated with the lost check will NOT be reported in an 835 transaction again .Only the payment will reissued.




3 comments:

Anonymous said...

Ah, great! This cleared up some contradictions I'd heard.

Anonymous said...

Amiable fill someone in on and this mail helped me alot in my college assignement. Thank you for your information.

Prashant Amle said...

If current check receives forward balance negative, then should we recoup that amount from current check if we receive recoupement for particular account.

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