Change Request Detail
No.
1053
Date
10/3/2006
Submitter
Type of Request
Payment of a Health Care Claim
Status
DSMO Process Completed
Business Reason
Would like to request a modification to the format of the PLB segment.  PLB for providers are a very manual and tedious process.   The use of clearing accounts to post PLB values to cause problems and are not recommended by our accounting and auditing department.  Some PLB qualifiers identify monies that need to apply to specific members.   A modified version of this segment could greatly reduce the manual work and provide a better audit trail.
Suggestion
Current PLB03-2 provides an identifier.   This is most commonly the payers claim/ICN number.   In the case of Medicare the HIC number is also provided.   HIC is most often the Social Security Number.  Non-Medicare payers report any internally assigned reference identifier for the related adjustment.  

As a provider it would benefit to receive the patient's unique account number that is sent to the payer in the 837 transaction, CLM01.   This is not needed in all PLB03-1 adjustment reason codes but certainly with many, example:  FB-Forward Balancing and WO-Withholding.

Create a new reference identification value to allow the CLM01 to be returned in the PLB segment.
DSMO Category
C
Recommendation
Approved. The DSMO agrees in principle with data content of the request although the technical solution as to how to carry the information forward is yet to be determined.  The issue will be addressed for the next guide and the submitter's suggestion will be taken into consideration. The PLB segment was originally intended to report positive or negative adjustments not related to a specific claim.  However the reality of usage within industry shows that there are valid business reasons for using this segment and the desire to return a patient control number.
Appeal Recommendation