Section title: Requests for Interpretation
RFI #
2289
NPI value in PLB for interest
Description

Interest (L6): Which NPI to put in the PLB01 when there is a Payee NPI in the N1 and one or more Service NPI(s) in the NM1*82? Should the payer send the payee NPI or the service provider(s) NPI in the PLB01?

REFERENCES:
-1.10.2.9: 'Convey the net for all claims..'
-NM1 (TR3 Note): 'provided to facilitate identification of the claim..
-PLB (Sit Rule): 'required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service'

EX1:
N1*PE*PAYEE*xx*NPI A
CLP*xxxxxxxxxx*1*xxx*xxx*xx*xx*CLAIM 1*11*1
NM1*82*2*SERVICE PROV 1*****XX*NPI B
AMT*I*21.00
CLP*xxxxxxxxxx*1*xxx*xxx*xx*xx*CLAIM 2*11*1
NM1*82*2*SERVICE PROV 2 *****XX*NPI C
AMT*I*12.00
PLB*NPI A*20181231*L6*-33

OR

EX2:
N1*PE*PAYEE*xx*NPI A
CLP*xxxxxxxxxx*1*xxx*xxx*xx*xx*CLAIM 1*11*1
NM1*82*2*SERVICE PROV 1*****XX*NPI B
AMT*I*21.00
CLP*xxxxxxxxxx*1*xxx*xxx*xx*xx*CLAIM 2*11*1
NM1*82*2*SERVICE PROV 2 *****XX*NPI C
AMT*I*12.00
PLB*NPI B*20181231*L6*-21
PLB*NPI C*20181231*L6*-12

Response

The PLB – Provider Adjustment segment is “Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send.” The purpose of the PLB is to make adjustments to provider payments not specific to a particular claim or service. Therefore, the NPI reported in the PLB01 must be the NPI of the provider who was paid in association with the payment(s) being adjusted.

DOCUMENT ID
005010X221A1