Provider Adjustments (PLB) in the Electronic Remittance Advice (835)
June 22, 2021
This paper will be published in a series of iterations, with updated information being provided in additional appendices. This will allow the WEDI Remittance Advice and Payments Subworkgroup (SWG) to provide information in a timely manner, while keeping all the related information in one paper (not requiring the reader to access multiple papers to gain the full set of information).
This updated version includes Appendix F - Regulatory PLBs, including Medicare-specific.
The purpose of this paper is to provide guidance and information on the functionality and usage of the Provider Adjustment Segment (PLB) within the electronic remittance advice (ASC X12N 835 transaction) for specific business use cases, as described in the appendices. This paper is not intended to be a primer on the 835 itself, but instead focuses on this specific function within the 835, and assumes some knowledge of the transaction for the reader. This paper is not a substitute for the ASC X12N 005010x221 Health Care Claim Payment/Advice (835) Technical Report Type 3 (TR3), which can be found at www.x12.org.
The PLB segment has historically been problematic for both payers and providers. Payers often do not provide all the necessary information in the 835 (for example, the Reference Identifier), and providers often are not able to correctly interpret the information provided.
In this paper, the SWG has looked at the different business use cases of the PLB, issues that commonly appear for those use cases, and provided some best practices to remediate challenges that both payers and providers experience. The initial sections of the document provide some level-setting information about the PLB and its usage, and then each appendix outlines a specific use case, along with challenges and best practices for that use case.