Provider-Level Balance (PLB) ( FB, WO, L6, 72, CS, OB)

 The PLB segment is used to transmit information about Provider-Level Adjustments - that is, payments and debts that are not specific to a particular claim or service

. PLBs can either increase or decrease a payment but will never be zero-dollar. The X12 T3 guide contains information about how the PLB is put together in sections 1.10.2.9, 1.10.2.10, 1.10.2.12, 1.10.2.16, and 1.10.2.17.

 Harvard Pilgrim is including this section in our companion guide for the 835 to provide additional clarity. PLBs may contain only a small amount of data to convey important information, so we hope this section will make it easier to understand what is being sent and why it is being sent.

Anatomy of the PLB segment

For most payees, PLB segments start with the NPI in the first element. For payees that are ineligible for an NPI, the first element of the PLB will have the recipient’s Harvard Pilgrim Payee Identifier.

Following that, all PLB segments sent by HPHC will have the last day of the year for the date in the PLB02- e.g., 20181231.

The PLB03 element contains a two-character Adjustment Code that identifies what the PLB segment is saying. The complete list of Adjustment Codes sent by HPHC is [72, B2, BD, CS, FB, L6, WO].

The PLB03 can be divided into sub-elements by a sub-delimiter “:” to include additional information about the debt or payment to which the Adjustment Code refers - e.g., *CS:12345678*. The additional information values are Adjustment Identifiers, and can be check numbers, payment numbers, payee numbers, or Harvard Pilgrim Claim numbers. The Adjustment Identifiers in the PLB03-2 may contain two of the above values separated by a hyphen “- “or a pipe “|” character

The PLB04 contains the dollar amount of the adjustment in question. PLEASE NOTE: If the dollar amount is negative, the adjustment is increasing the payment from Harvard Pilgrim Health Care to the payee. If the dollar amount is positive, the adjustment is reducing the payment from Harvard Pilgrim Health Care to the payee.

PLBs segments can each contain multiple adjustments. PLB elements 5 and 6; and PLB elements 7 and 8 each work the same as PLB elements 3 and 4 respectively. If a second or a third adjustment is sent in a PLB segment, the NPI in the PLB01 applies to all three adjustments.

A remittance may also include several PLB segments referencing additional adjustments to a single payment.

A PLB segment with 1 adjustment code

PLB*1127835124*20181231*FB:2005005500*340.08~

A PLB segment with 3 adjustment codes

PLB*1456378133*20181231*72:180113M51911*-58.92*B2: 180113M51911*-58.92*WO: 180113M51911*58.92~

A pair of related PLB segments

PLB*1992656770*20181231*FB:2001005655*20.81~

PLB*1992656770*20181231*OB:2001004373-XY44*-20.81~

A PLB segment will reference either a previous payment, a previous claim, or the current payment in which it is found. It is important to note that there may be older related payments or claims that were involved in the creation of the adjustment. Check the referenced payment to see if it also contained PLB segments referring to prior claims or payments.

Adjustments That Increase the Payment to the Trading Partner:

Interest Owed “L6”

If a Health Care Claim accrued interest on top of the regular payment due, the payment may include an “Interest Owed” PLB segment. In the remittance, a claim will have an AMT segment with the qualifier “I” followed by the value of the interest that claim has accrued, however, per the T3 guide, that AMT segment is not used in balancing the payment. Instead, the PLB will contain all the interest payments, either totaled or separately in multiple PLBs.

The PLB will have the “L6” Adjustment Code, followed by the amount of interest being paid. Note that a negative value means a positive payment to the payee.

AMT*I*1.51~ Informational segment in claim remittance

PLB*1737552660*20181231*L6*-1.51~ “L6” Adjustment Code and a positive adjustment of $1.51 for the interest paid

Authorized Return “72”

If Harvard Pilgrim Health Care makes an overpayment on a claim, and the payee sends back a check to return the overpayment, a PLB will be sent which acknowledges the received check. 

The PLB segment will have a “72” Adjustment Code followed by the received check number as the Adjustment Identifier. 

Note that an Authorized Return can be distinguished from an overpayment rebate as there will be no additional “WO” or “B2” Adjustment Codes in this PLB. When an Authorized Return is sent, it will be accompanied by a PLB with a Forward Balance Applied that has an equal but opposite value showing that the overpayment has been corrected.

PLB*1578581708*20170201*FB: 1326235788*500~ A negative value Forward Balance Applied for the amount of the initial overpayment by HPHC

PLB*1578581708*20170101*72:1000231*-500~ A 72 Adjustment Code followed by the check number “1000231” and a positive payment of $500

Forward Balance Remainder “FB”

It is possible for a claim adjustments and retractions or an existing Forward Balance to reduce the total payment below zero when it is applied.

 Because a payment cannot be negative, a Forward Balance Remainder is created to balance the transaction. This Forward Balance will be exactly enough to bring the negative payment back to $0.00.

The PLB segment containing the Forward Balance Remainder will contain an “FB” adjustment code and will be followed by the payment number from the current payment’s TRN segment.

 This is the amount that will be carried forward to the next available payment to the same payee where it will then appear as a Forward Balance that is either applied or continued as an existing balance.

The Forward Balance Remainder may accompany any of the other scenarios in this guide where the end result would be a negative payment without it.

TRN*1*2005007870*1999999999*HPHC~ The TRN segment from the remittance showing the current payment number in the TRN02

PLB*1762723340*20181231*FB:2005007870*-26.34~ A positive FB adjustment of $26.34 brings this payment from a negative to $0.00. The $26.34 will be accounted for on the next payment as a negative balance

Rebate “B2”

If Harvard Pilgrim receives a check that we do not believe we are owed, we return the full amount of that check sent, we will send a PLB with a “B2” Adjustment Code. The “B2” will be followed by the check number on which the payment was sent.

PLB*1588606123*20161101*B2:462872*-500~ The B2 Adjustment Code here shows that $500 was paid to the payee to return the payment from check #462872

Void-Reissue “CS”

Harvard Pilgrim Health Care may void a previous payment and then reissue the payment with a new payment or check number. 

The PLB segment will have a “CS” Adjustment Code. The first Adjustment Identifier will be the voided payment number, followed by a hyphen, and then the originating Harvard Pilgrim Claim Number.

PLB*1211452365*20130524*CS:1234591-180113M24823*-14.99~ Check number 1234591 for HPHC Claim Number 180113M24823 has been voided, the current payment has been increased by $14.99 to reissue the voided check

Overpayment Rebate to Provider “B2”, “72”, “WO”

An Overpayment Rebate to Provider is when Harvard Pilgrim Health Care returns a portion of a payment received from a payee after using some of it to cover a negative balance. This type of adjustment will always have 3 Adjustment Codes: B2, 72, and WO.

The amount of the check that is being returned to the payee as a rebate will be indicated with a “B2” qualifier, followed by the number of the check sent by the payee to Harvard Pilgrim Health Care.

Then, there will be an Authorized Return “72” qualifier to indicate the negative value which is being paid with the check from the payee. This is followed by the Harvard Pilgrim claim number, if there is a claim being paid, and then a pipe “|” delimiter, and then the check number again.

Finally, there will be a “WO” qualifier followed by the same claim number and check number in the “72” Authorized Return, this is used to balance the remittance and will offset the value of the return.

It is possible to have many Authorized Returns indicating negative balances paid in relation to a single Overpayment Rebate to Provider. If so, there will be one “B2”, and as many “72” and “WO” pairs as needed to show all the negative balances being paid.

PLB*1551321085*20181231*B2:158751*-28.02*72:170814JP1411|158751*-58.92

*WO:170814JP1411|158751*58.92~ For Harvard Pilgrim Claim Number 170814JP1411, a check, number 158751, was sent to Harvard Pilgrim for $86.94. $58.92 of that check was used to pay off claim 170814JP1411. The remaining

$28.02 is being returned to the payee as a rebate.

PLB*1551321085*20181231*B2:6047*-1726.25*72:180312M6216|6047*-24.70

*WO: 180312M6216|6047*24.70*72:180224M8991|6047*-255.2

*WO:180224M8991|6047*255.2~

PLB*1551321085*20181231*72:180214JP6561|6047*-114.37*WO:180214JP6561|6047*114.37*72: 180312M6216|6047*-58.32*WO:180312M6216|6047*58.32*72:180313M7817|6047*-66.4

*WO:180313M7817|6047*66.4~

A payment was received by Harvard Pilgrim on check # 6047 for $2245.24. That amount was used to pay off 5 claims totaling $518.99. The remaining balance of $1726.25 is returned as a rebate.

Negative Balance Transfer from a Payee “OB”

There are occasions where a payee may not have sufficient claims volume to cover a negative balance on their account. When this occurs, Harvard Pilgrim may transfer that negative balance to another payee account of the same organization. This is accomplished by two separate PLB segments.

 One will be the Negative Balance Transfer from a Payee, which removes the debt from a payee’s account, and the other is a Negative Balance Transfer to a Payee, which will appear on the other Payee’s remittance and shows the negative balance being added to their account.

For the Negative Balance Transfer from a Payee, there will be an “OB” Adjustment Code. This will be followed by two Adjustment Identifiers separated by a hyphen.

 The first Adjustment Identifier will be the payment number of the current remittance.

 The second Adjustment Identifier, found after the hyphen, will be a Harvard Pilgrim Payee number; the account of that payee will inherit the debt of that negative balance.

The value of the PLB will be a negative number. That number will eliminate all of the negative balance on this payee’s account. Harvard Pilgrim will never transfer part of a negative balance to another payee.

The Negative Balance Transfer From is always accompanied by another PLB segment in the same remittance. That PLB will show the value of the negative balance currently on the payee’s account - (See Forward Balance Applied)

PLB*1992794770*20181231*FB:2001000355*20.81~ Existing Negative Balance in a “Forward Balance Applied” adjustment

PLB*1992794770*20181231*OB:2001004983-10001401*-20.81~ Negative Balance Removed from ZZ37 and forwarded to payee 10001401

Negative Balance Transfer from a Pay Group “OB”

Negative Balance Transfers from a Pay Group are used when Harvard Pilgrim Health Care has transferred the handling of a debt between internal legal entities. This transaction will always be paired in another remittance. (See Negative Balance Transfer to a Pay Group)

The PLB segment for the transfer will contain an “OB” Adjustment Code followed by the payment number from the current remittance, then a hyphen, and then the payee number of the current payee.

 The monetary amount will be a negative number showing the amount needed to eliminate the negative balance being handled by the Pay Group in the N1 segment of this remittance.

Unlike the Negative Balance Transfer from a Payee, the Negative Balance Transfer from a Pay Group does not move the debt off of the payee who currently holds it. Instead, it moves the handling of that debt between the legal entities at Harvard Pilgrim Health Care that handle either indemnity or commercial claims payments.

The Negative Balance Transfer from a Pay Group PLB will be accompanied by another PLB containing the origin of the negative balance in question. (See: Forward Balance Applied)

N1*PR*HPHC INSURANCE COMPANY, INC.~ The remittance containing the negative balance was originally under the legal entity at Harvard Pilgrim which handles indemnity claims payments

PLB*1587882160*20181231*FB: APNOCHK2016999*15~ Payment number APNOCHK2016999 has left a $15 negative balance on the payee’s account

PLB*1587882160*20181231*OB:2000006862-12BB*-15~ $15 is being added to this payment to eliminate the debt under the indemnity Pay Group at Harvard Pilgrim Health Care. The debt is on payee 12BB’s account, and will reappear there in the next remittance under the Commercial Pay Group

Bad Debt Write Off “BD”, “FB”

When there is a debt that Harvard Pilgrim Health Care has determined cannot be collected, we will issue a Bad Debt Write Off transaction.

 In it, the PLB segment will have an “BD” Adjustment Code followed by the payment number of the current remittance. 

The following value will be an increase in payment sufficient to erase the existing bad debt. There will be an additional PLB that shows the amount of the negative balance that is being erased which will be the opposite of the Bad Debt Write Off adjustment (see: Forward Balance Applied).

PLB*1422662856*20181231*FB:2004002101*46.48~ This is the Bad Debt currently on the payee’s account

PLB*1422662856*20181231*BD:2001005042*-46.48~ The current remittance - with payment number 2001005042 - increases by $46.48 to eliminate the bad debt

Adjustments That Decrease the Payment to the Trading Partner:

Forward Balance Applied “FB”

When a payee owes money to Harvard Pilgrim Health Care, that forward balance will be reconciled on the next available payment.

 The total money in the payment will be reduced as the Forward Balance is applied to it, and the payment may end up being $0.00 if the positive payments are less than or equal to the negative Forward Balance Applied.

When a forward balance is applied, there will be a PLB segment with an “FB” adjustment code. 

The code will be accompanied by the payment number from which the forward balance originated, and the monetary amount will be a positive number. The positive number is the amount the payment is being reduced.

PLB*1587882160*20181231*FB:2002044324*340.08~ Payment number 2002044324 resulted in a debt of $340.08 being owed to Harvard Pilgrim, that negative balance is carried forward to this remittance

Negative Balance Transfer to a Payee “OB”

The Negative Balance Transfer to a Payee is part of a paired set of adjustments (See: Negative Balance Transfer from a Payee).

 It is used to show that an outstanding balance is being added to the current payee after being removed from another related payee under the same organization.

When a Negative Balance Transfer to a Payee occurs, Harvard Pilgrim Health Care will send a PLB segment with an “OB” adjustment code. 

The code will be accompanied by the payment number that contained the Negative Balance Transfer From, followed by the payee number of the payee from whom the debt is being transferred. 

The two identifiers will be separated by a hyphen. The monetary value will positive and will reduce the overall payment to the recipient as the debt from the other payee has been inherited by this account.

The inherited debt may be more than the total amount of claims paid on this remittance, in which case there will be an additional PLB segment that shows the remaining debt being carried forward (See: Forward Balance Remainder)

Example 1:

PLB*1023298344*20181231*OB:5005214677-ZZX5*352.64~ A debt of $352.64 has been inherited by the current payee from related payee ZZX5. The payment number 5005214677 for payee ZZX5 will show the debt being removed from that payee

Example 2:

PLB*1023129782*20181231*FB:2000006387*1444.54~ The claims on this remittance did not cover the inherited negative balance, so a Forward Balance Remainder shows $1,444.54 of debt being carried forward to the next payment

PLB*1023129782*20181231*OB:500322268-90604*2878.62~ A debt of $2878.62 has been inherited by the current payee from related payee 90604. The payment number 500322268 for payee 90604 will show the debt being removed from that payee

Negative Balance Transfer to a Pay Group “OB”

Negative Balance Transfers to a Pay Group are used when Harvard Pilgrim Health Care has transferred the handling of a debt between internal legal entities. This transaction will always be paired in another remittance. (See Negative Balance Transfer from a Pay Group)

The PLB segment for the transfer will contain an “OB” Adjustment Code followed by the payment number from the current remittance, then a hyphen, and then the payee number of the current payee. The monetary amount will be a positive number showing the amount of the negative balance being re-added to the payee under the Pay Group in the N1 segment of this remittance.

Unlike the Negative Balance Transfer to a Payee, the Negative Balance Transfer to a Pay Group does not move the debt to the payee in this remittance from another payee. Instead, it moves the handling of that debt between the legal entities at Harvard Pilgrim Health Care that handle either commercial or indemnity claims payments.

If the Negative Balance Transfer to a Pay Group PLB creates a debt greater than the total of claims payments in this remittance, there will be a PLB to increase the payment to $0.00 and carry the debt forward. (See: Forward Balance Remainder)

N1*PR*HARVARD PILGRIM HEALTH CARE~ The remittance containing the negative balance was originally under the legal entity at Harvard Pilgrim which handles commercial claims payments

PLB*1587882160*20181231*OB:2000006862-12BB*15~ A $15 debt is being applied to this payment to re-establish the debt under the commercial Pay Group at Harvard Pilgrim Health Care. The debt was from the same payee that is on the current remittance, but now under the commercial Pay Group.

Insufficient Refund to Offset Debt “CS”, “72”, “WO”

When Harvard Pilgrim Health Care receives a refund from a payee, but the refund does not cover the total value of the negative balance due, an Insufficient Refund to Offset Debt PLB segment will be sent. 

The value of the check that was sent will be shown with a “72” Adjustment Code and a followed by a Harvard Pilgrim Claim Number, a pipe “|”, the check number, and then the amount of the check.

 The “WO” Adjustment Code will show the same Adjustment Identifiers, and then the same, but opposite value to balance the remittance and show that the actual amount of the adjustment was different.

 The “CS” Adjustment Code will have the value of the remaining debt after the check was applied to it, followed by the number of the check received.

PLB*1309862341*20170306*CS:43455*33.45*WO:180120M21G11|43455*63.27

*72: 180120M21G11|43455*-63.27~ Check number 43455, for $63.27, was received to cover the debt from Harvard Pilgrim Claim Number 180120M21G11, however $33.45 is still owed