The 835 TR3 guide in the overpayment and recovery section does not describe how to handle overpayments received from another payer (not the one originally paid). The PLB Adjustment reason codes also are not clear on what is the best code to identify refund received from other Source. We have business situation as such: Claim is paid to Provider X for 100. Later it is identified that it is Workers Comp related. The Provider does not send us the refund; the workers comp insurer sends us the refund. In the past when we have sent a 'corrected' 835 showing the claim is WC and 'denied by us and show in a PLB the refund. The provider has no understanding that WC refunded the money to us - they get confused. In reality the provider is still made whole as no monies are recouped from them. The provider then bills the member. 1 Are we required to acknowledge these refunds from WC in the ERA (with the corrected claim) to the provider and 2 how can this be accurately relayed in the ERA?
The 835 TR3 does not address the Worker's Comp scenario described. The process currently would not be handled within an 835, but rather directly via letter or other communication. Some state regulations, for example Florida, may allow the provider to collect a co-payment or deductible from the patient, if applicable.