Thursday, August 2, 2012

what is WO - withholding and FB - Forward balance with exapmple

PROVIDER ADJ DETAILS

The provider-level adjustment details section is used to show adjustments that are not specific to a particular claim or service on this SPR.

PLB REASON CODE – This field indicates the various provider-level adjustment reason codes that may be used. Examples include:


• 50 – Late charge – Used to identify Late Claim Filing Penalty.

• L6 – Interest owed – Used for the interest paid on claim on an RA.

• WO – Withholding – Used to recover previous overpayments. A reference number (the original ICN) is applied for tracking purposes. The WO amount is subtracted from the check amount.

• FB – Forwarding Balance – Reflects the difference in the payment between the original claim and the overpayment/adjustment to the original claim. An FB will be on an RA any time a claim has been overpaid/adjusted. This amount does not reflect a withholding on this claim. Providers should receive a letter requesting this amount and instructions for refund. If the refund is not received in approximately 45 days, the amount will be reflected as a “WO” on a future remittance.

When the adjustment shows a corrected payment of less than the original claim payment, an FB reflects a negative amount. When the adjustment shows a corrected payment of more than the original claim payment, the FB reflects a positive amount.

The RA will identify the associated FB with the FCN (ICN).


FCN – Indicates the Financial Control Number (FCN) that this adjustment relates to when the adjustment refers to a claim that appeared on a previous RA. This usually matches the ICN field of a previous claim. If the adjustment in question does not relate to a previous claim, this field is left blank.

AMT – This field indicates the amount of the provider-level adjustment. These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number).



My remittance advice (RA) contained code LE - Levy. What does this mean?


Some adjustments that are made on a RA (remittance advice) are not related to a specific claim or service. These adjustments are made at the provider level, and are described by codes called Provider-Level Adjustment Reason Codes. Provider level reason code LE is assigned to report federally mandated recoupments and/or bonus payments; this can be an additional payment or reduction.

If the LE adjustment code includes a phone number in the description (usually starting with 800), then this is a tax levy and you will need to call that telephone number for more information.

If the LE adjustment code is not accompanied by a telephone number, then the LE adjustment code is detailing an incentive payment (example eRx or PQRS).

For more information, visit the CMS websites on the Physician Quality Reporting System (PQRS) external link  or ePrescribing Incentive Programs external link .

All other inquiries should be directed to the appropriate Provider Contact Center.


What does forwarding balance mean on my remittance notice?
Answer:

Forwarding balance means that 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.

What does that mean?

A negative value represents a balance that will be moved forward to a future remittance payment advice. This means that an overpayment for a specific claim or claims (on this remittance) has been created because Medicare has paid for a service that should not have been allowed or has paid too much for a service. Your remittance notice will show the corrected allowed amounts for the adjusted claim(s).

A positive value represents a balance that is being applied from a previous remittance advice. This means we are notifying you that we have completed an adjustment on a claim or claims (included in this remittance) and we have determined that an additional payment is due in part or in full for a previously processed service(s). Your remittance notice will show the corrected allowed amounts for the adjusted claim(s). A reference number (the original ICN and HIC) will be provided for tracking purposes.

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.)

PLB*9999999999*20141231*FB|TRN02CheckA*100


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 - TRN02checkA
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKA*-37.5~


Day 2: Check B
Provider number = 1234
Overpayment = 200.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02checkB
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKB*-125.00~


Day 3: Check C
Provider number = 1234
Overpayment = 300.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02checkC
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKC*-300.00~


DAY 4: Check D
Second subsequent remittance (different day/check/eft):
TRN02 value – TRN02checkD
Balance yet to be satisfied is $37.50, 125.00 and 300.00 = 462.50
The remittance only has sufficient funds to offset $237.50 (CheckA 37.50 and Check B 125.00 and check C 200.00) with
balance left of 100.00
The remittance would ONLY have the following:

PLB*1234*20011231*FB: TRN02CHECKA*37.50*~
PLB*1234*20011231*FB: TRN02CHECKB*125*~
PLB*1234*20011231*FB: TRN02CHECKC*300*FB: TRN02CHECKD*-100~


OVERPAYMENT/ADJUSTMENT


ADJS – Adjustment.

PREV PD – Displays the amount the provider was previously paid on this claim.

INTEREST – Interest amount.

LATE FILING CHARGE – Amount charged to the provider for filing a claim past the claim filing time limits.

PROV PD AMT – The provider paid amount is the total net amount (the amount Medicare owes the provider for this claim) minus any Forwarding Balance (FB).



PROV ADJ AMT – The provider adjustment amount is the total amount of any Withholding (WO) amounts. Provides the amount the check has been adjusted from the provider’s paid amount.

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