Provider receives upfront payment for services to be rendered via debit card. Provider has 60 days to submit claim. When NO claim is received Payer per regulations the payer must then off set any future claim payments to that provider (Clip). In the next 835 ERA where the provider is to receive payment for other claims, payer will offset check for the debit owed amount. The PLB will be present to balance and identify the debit being offset. Would the PLB03-1 be LS? as an fyi we will be sending a PLB03-2 to identify the debit card recoupment.
Note this is not a PI situation, the original debit occurs at the time the services are approved on a claim by claim basis.
While guide 005010X221 section 1.10.2.17 is titled "Claim Overpayment Recovery" and doesn't directly apply, the principles related can be applied to the stated situation. This situation is closest to having reported a claim overpayment recovery via letter and using the PLB segment to recoup funds when not returned by the provider. Since PLB03-01 code LS (Lump Sum) is specific to types of adjustments identified in the guide note (including disproportionate share adjustment and various passthrough amounts), it is not appropriate for this function.
PLB03-01 code WO (Overpayment Recovery) has a note that states "This is the recovery of previous overpayment...". That note is not specificaly limited to claim overpayment recoveries. Since this is an overpayment recovery, code WO applies to this situation.
In this response, it is assumed that the provider has used the debit card, thereby taking the payment. If the provider has not used the debit card then overpayment recovery and the 835 are inappropriate actions as that then represents recoupement/return of the debit card, and not the related funds.