It isn't explicitly clear in the spec, and the example has both adjustments on the same line.
The specification states:
""If the provider chooses to remit the balance due within the specified time period with a
check, the health plan will acknowledge the receipt of the check using the PLB segment
of the next 835. In order to maintain a balanced 835, this is accomplished using offsetting
adjustments in the PLB. PLB03-1 codes 72 (Authorized Return) and WO (Overpayment
Recovery) are used.
Example: A health plan sends a letter to a provider (number 1234) identifying an
overpayment of $37.50.The FCN of the document is 56473. Before the specified deadline,
the provider remits the overpayment to the health plan, identifying the FCN with the
payment. A PLB segment in the next 835 would report this payment.
PLB*1234*20011231*WO:56473*37.5*72:56473*-37.5~
Is sending the ""WO"" adjustment on a separate/preceeding PLB segment line from associated adjustement type ""72"" a valid usage of those adjustments?"
We receive an 835 file that is valid otherwise, but our platform is rejecting it based on the below segments. Below are the segments causing the file to reject.
PLB*1740348929*20231231*L6*.14*WO:4055597501*-100*WO:4055597501*100*72:4055597501*-100*WO:40852669600*-44.4*WO:40852669600*44.4~
PLB*1740348929*20231231*72:40852669600*-44.4~
Below is the error from the 999 file
"~AK2*835*0146"
"~IK3*PLB*371**8"
"~CTX*SITUATIONAL TRIGGER*PLB*371**3:1"
"~CTX*TRN02:EPICTAP305595"
"~IK5*R*I5"
It is not explicitly clear in the spec, and the example has both adjustments on the same line.
Example: A health plan sends a letter to a provider (number 1234) identifying an
overpayment of $37.50.The FCN of the document is 56473. Before the specified deadline,
the provider remits the overpayment to the health plan, identifying the FCN with the
payment. A PLB segment in the next 835 would report this payment.
PLB*1234*20011231*WO:56473*37.5*72:56473*-37.5~"
The PLB adjustment reason codes WO and 72 do not have to be in the same PLB segment. There is no explicit rule or guidance in the 005010A1 TR3 guide to advise what type of adjustment combinations should be sent in each PLB segment.
Within a given PLB segment, when all 6 of the adjustments are exhausted (used), a new PLB segment must be generated to show any additional adjustments to be reported. In the example provided there were 7 adjustments to be reported. Six were in the first PLB and one in the subsequent.