Section title: Requests for Interpretation
RFI #
2326
Suppressed Payment Agreements
Description

TR3 PLB J1 Adjustment reason code states it is used to offset the claim/service data to prevent issuance of payment. Based upon verbiage in the TR3 we feel it is compliant to use PLB J1 to suppress provider-employer claim payments. This only applies when the service provider is the employer group and they want their monies applied to their premium payments.

In essence the J1 would work similar to the PLB WO where you are reporting claim/service payments only suppressing the financial impact of transaction payment total with the monetary amount of the impacted claims in the PLB J1.
This approach was implemented before RFI 2157 existed and seems to meet the TR3 guidelines for use of the PLB-J1. This method is used by more than one payer. Is this a compliant alternative?
835 Excerpts:
BPR*H*0*C*NON************20180808~
TRN*1*43211032517*1411289245*ABC1234~
CLP*987654321*1*8301.58*1913**13*111111111*13*1~
PLB*1111111111*20181231*J1: SUPPRESSED PAYMENT ARRANGEMENT*1913~

Response

The workgroup has identified two scenarios or models that cover this or similar situations:
1) The provider is also the plan sponsor / employer group, the patient is their employee (or on the employee's plan), and there is an agreement / contract to suppress payment. In this model, no funds actually move between the plan and the provider.outside of the remit process.
2) The provider is also the plan sponsor / employer group, the patient is their employee (or on the employee's plan), and there is an agreement / contract to suppress payment. In this model, funds are moved outside of the remit process to be applied to their premium payments per the contracted agreement.
Model 1 is the situation outlined in RFI 2157, and is addressed in that RFI.
Model 2 is the situation described in this RFI. In this scenario, because funds are being moved, including the claim / service payment amount in CLP04 / SVC03 is appropriate, since payment is actually being made on the claim / service. Use of the PLB code J1 is also appropriate to reflect the suppressed payment amount. Note that the claims being included in the suppressed payment amount must be indicated as such so the provider is aware of the disposition of the payment of their claims.

RFI Recommendation

For claims that fall under Model 1, report the amounts as described in RFI 2157. Providers can calculate the amounts included in the suppression amounts from the CAS segments reported at the claim/service level, regardless of how claims are grouped within the 835
For claims that fall under Model 2, report the payment amounts for the claims in CLP04 (or service in SVC03), and the suppressed payment amount in the PLB using Provider Adjustment Code J1. The payer must indicate which claims are included in the suppressed payment amount, and must communicate with the provider how that information will be conveyed (e.g. grouping all suppressed claim payments into a single 835 or including a separate PLB trio for each claim, using the J1 Provider Adjustment Code in PLB03-01, and including the CLP01 from the impacted claims in the Reference ID field PLB03-02).

DOCUMENT ID
005010X221A1