Is it a requirement for health plans to return subrogation claim ADJUSTMENTS on the 835? Or is it at the discretion of the health plan whether or not to do so?
Can these be omitted from the 835?
The health plan processes a claim and makes a payment to the provider. It is later determined that the services rendered were due to a car accident. The auto insurance company voluntarily refunds to the health plan the payment amount that was originally made by the health plan to the provider.
The health plan then adjusts the claim and returns it on the 835 to show that the original payment was reversed and also uses the PLB segment in that same 835 to reflect that the money was “added back” into the current total payment. This is to ensure that NO FUNDS are reduced from the provider’s current total payment that is reflected on the 835 and also ensures balancing.
Returning these adjustments and the related PLB causes confusion to the providers (even with the PLB being supplied), and causes posting errors in their system. They still feel as if the health plan is taking money back from them, when this is not the case.
Example for reference:
CLP*FM12345*22*-1715*-1113.62**ZZ*211564784500*13*1
CAS*PR*2*-196.51
CAS*CO*45*-404.87
CLP*FM12345*2*1715*0*601.38*12*211564784501*13*1
CAS*PR*2*196.51**215*404.87
CAS*OA*22*1113.62
PLB*1366436123*20241231*WO:211564784500 FM12345*-1113.62
There is no requirement or best practice to return or not return subrogation claims in the 835. This would need to be a discussion between the parties involved on whether to do so.
Please refer to Section 1.10.2.16 Post Payment Recovery for additional information.
A best practice would be to notify, if necessary, the provider outside of the 835 processes.