Code

Name

Late Charge

Use this code for the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. PLB03-2 identifies the Medicare Late Cost Report Penalty with a code value of LR.

Interest Penalty Charge

Use this code for the interest assessment for late filing. Medicare Part A provides code “IP” in PLB03-2.

Authorized Return

This monetary amount is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 should always contain an identifying reference number when the value isused. PLB04 should contain a negative value. This adjustment should always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. Medicare A will provide code “PR” in PLB03-2.

Early Payment Allowance

Origination Fee

This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims.

Applied to Borrower's Account

See 2.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this monetary amount for the loan repayment amount.

Acceleration of Benefits

Use this code to reflect accelerated payment amounts or withholdings. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. Medicare Part A will provide code “AP” for accelerated payment amounts and code “AW” for accelerated payment withholdings in PLB03-2.

Rebate

Use this code for the refund adjustment. Medicare Part A will provide code “RF” in PLB03-2.

Recovery Allowance

This code is used by Medicare to represent the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. Part A or Part B trust fund for Medicare use is identified in PLB03-2. “RA” is used for Medicare A. “RB” is used for Medicare Part B. PLB04 should contain a NEGATIVE value. This adjustment should always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset.

Bad Debt Adjustment

Use this code for the bad debt passthrough. Medicare Part A will provide code “BD” in PLB03-2.

Bonus

See 2.2.10, Capitation and Related Payments or Adjustments, for additional information.

Temporary Allowance

This is the tentative adjustment. Medicare Part A will provide code “TS” in PLB03-2.

Capitation Interest

See 2.2.10, Capitation and Related Payments or Adjustments, for additional information.

Adjustment

Provide supporting identification information in PLB03-2. Medicare Part A will provide code “CA” for Manual Claim Adjustment, “AA” for Receivable
Today. Medicare Part A and Part B will provide code “RI” for Reissued Check Amount in PLB03-2.

Capitation Payment

See 2.2.10, Capitation and Related Payments or Adjustments, for additional information.

Capital Passthru

Medicare Part A will provide code “CP” in PLB03-2.

Certified Registered Nurse Anesthetist Passthru

Medicare Part A will provide code “CR” in PLB03-2.

Direct Medical Education Passthru

Medicare Part A will provide code “DM” in PLB03-2.

Withholding

See 2.2.10, Capitation and Related Payments or Adjustments, for additional information. Medicare Part A will provide code “CW” in PLB03-2.

Forwarding Balance

Use this monetary amount for the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number should be supplied in PLB03-2 for tracking purposes. Medicare Part A will provide code “BF” for negative values and “CO” for positive values in PLB03-2.

Fund Allocation

See 2.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund should be identified in PLB03-2.

Graduate Medical Education Passthru

Medicare Part A will provide code “GM” in PLB03-2.

Incentive Premium Payment

See 2.2.10, Capitation and Related Payments or Adjustments, for additional information.

Internal Revenue Service Withholding

Interim Settlement

Use this number for the interim rate lump sum adjustment. Medicare Part A will provide code “IR” in PLB03-2.

Nonreimbursable

Use this to offset claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment.

Penalty

Use this number for the capitation-related penalty, penalty withholding, or penalty release adjustment. Withholding or release is identified by the sign in PLB04. See 2.2.10, Capitation and Related Payments or Adjustments, for additional information. Medicare Part A will provide code “PW” for Penalty Withhold, “RS” for Penalty Release, and “SW” for Settlement Withhold Amount in PLB03-2.

Interest Owed

Use this monetary amount for the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is “I. ”Medicare Part A will provide code “IN” in PLB03-2.

Levy

IRS Levy

Lump Sum

Use this for a disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum
adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. Medicare Part A will provide code “DS” for Dispropiortinate Share Adjustment, “IM” for Indirect Medical Education Passthrough, “NP” for Non-physician Passthrough, “PS” for Passthrough Lump Sum, and “PO” for Other
Passthrough in PLB03-2.

Organ Acquisition Passthru

Medicare Part A will provide code “KA” in PLB03-2.

Offset for Affiliated Providers

Part A or Part B trust fund identification for the source of the offset is in PLB03-2. Use “OA” for the Part A trust fund and “OB” for the Part B trust fund in PLB03-2.

Periodic Interim Payment

Use this monetary amount for the PIP lump sum, PIP payment, or adjustment after PIP. The sign of the amount in PLB04 determines whether this is a payment (negative) or adjustment (positive). Medicare Part A will provide code “PL” for PIP Lump Sum, “PP” for PIP Payment, and “PA” for Adjustment After PIP in PLB03-2.

Payment Final

Use this number for the final settlement. Medicare Part A will provide code “FS” in PLB03-2.

Retro-activity Adjustment

See 2.2.10, Capitation and Related Payments and Adjustments, for additional information. Medicare Part A will provide code “TR” in PLB03-2.

Return on Equity

Medicare Part A will provide code “RE” in PLB03-2.

Student Loan Repayment

Third Party Liability

See 2.2.10, Capitation and Related Payments or Adjustments, for additional information.

Overpayment Recovery

Use this for the recovery of previous overpayment. An identifying number should be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. Medicare Part A will provide code “OR” in PLB03-2.

Unspecified Recovery

Use this for the outside recovery adjustment. Medicare Part A will provide code “OS” in PLB03-2.

Mutually Defined

NOT ADVISED
Use this to report hemophilia clotting factor supplement amount until data maintenance approved by ASC X12.

	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Provider Adjustment Identifier Medicare intermediaries must enter the applicable Medicare code (see Medicare A notes in PLB03-1) in positions 1-2, the Financial Control Number or other pertinent identifier in positions 3-19, and the patient’s Health Insurance Claim Number (HIC) in positions 20-30 when the adjustment is related to a previously processed claim. Non-Medicare payers report any internally assigned reference identifier for the related adjustment.	O	AN	1/30	Situational
PLB04	782	Monetary Amount Description: Monetary amount Industry: Provider Adjustment Amount Use this monetary amount for the adjustment amount for the preceding adjustment reason.	M	R	1/18	Required
PLB05	C042	Adjustment Identifier Description: To provide the category and identifying reference information for an adjustment See PLB03 for details. Used when additional adjustments apply.	C	Comp		Situational
	426	Adjustment Reason Code Description: Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment All valid standard codes are used.	M	ID	2/2	Required
	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Provider Adjustment Identifier	O	AN	1/30	Situational
PLB06	782	Monetary Amount Description: Monetary amount Industry: Provider Adjustment Amount Use this monetary amount for the adjustment amount for the preceding adjustment reason.	C	R	1/18	Situational
PLB07	C042	Adjustment Identifier Description: To provide the category and identifying reference information for an adjustment See PLB03 for details. Used when additional adjustments apply.	C	Comp		Situational
	426	Adjustment Reason Code Description: Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment All valid standard codes are used.	M	ID	2/2	Required
	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Provider Adjustment Identifier	O	AN	1/30	Situational
PLB08	782	Monetary Amount Description: Monetary amount Industry: Provider Adjustment Amount Use this monetary amount for the adjustment amount for the preceding adjustment reason.	C	R	1/18	Situational
PLB09	C042	Adjustment Identifier Description: To provide the category and identifying reference information for an adjustment See PLB03 for details. Used when additional adjustments apply.	C	Comp		Situational
	426	Adjustment Reason Code Description: Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment All valid standard codes are used.	M	ID	2/2	Required
	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Provider Adjustment Identifier	O	AN	1/30	Situational
PLB10	782	Monetary Amount Description: Monetary amount Industry: Provider Adjustment Amount Use this monetary amount for the adjustment amount for the preceding adjustment reason.	C	R	1/18	Situational
PLB11	C042	Adjustment Identifier Description: To provide the category and identifying reference information for an adjustment See PLB03 for details. Used when additional adjustments apply.	C	Comp		Situational
	426	Adjustment Reason Code Description: Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment All valid standard codes are used.	M	ID	2/2	Required
	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Provider Adjustment Identifier	O	AN	1/30	Situational
PLB12	782	Monetary Amount Description: Monetary amount Industry: Provider Adjustment Amount Use this monetary amount for the adjustment amount for the preceding adjustment reason.	C	R	1/18	Situational
PLB13	C042	Adjustment Identifier Description: To provide the category and identifying reference information for an adjustment See PLB03 for details. Used when additional adjustments apply.	C	Comp		Situational
	426	Adjustment Reason Code Description: Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment All valid standard codes are used.	M	ID	2/2	Required
	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Provider Adjustment Identifier	O	AN	1/30	Situational
PLB14	782	Monetary Amount Description: Monetary amount Industry: Provider Adjustment Amount Use this monetary amount for the adjustment amount for the preceding adjustment reason.	C	R	1/18	Situational

1.	P0506 - If either PLB05,PLB06 is present, then all are required
2.	P0708 - If either PLB07,PLB08 is present, then all are required
3.	P0910 - If either PLB09,PLB10 is present, then all are required
4.	P1112 - If either PLB11,PLB12 is present, then all are required
5.	P1314 - If either PLB13,PLB14 is present, then all are required

1.	PLB01 is the provider number assigned by the payer.
2.	PLB02 is the last day of the provider's fiscal year.
3.	PLB03 is the adjustment information as defined by the payer.
4.	PLB04 is the adjustment amount.
5.	PLB05 is the adjustment information as defined by the payer.
6.	PLB06 is the adjustment amount.
7.	PLB07 is adjustment information as defined by the payer.
8.	PLB08 is the adjustment amount.
9.	PLB09 is adjustment information as defined by the payer.
10.	PLB10 is the adjustment amount.
11.	PLB11 is adjustment information as defined by the payer.
12.	PLB12 is the adjustment amount.
13.	PLB13 is adjustment information as defined by the payer.
14.	PLB14 is the adjustment amount.

Ref	Id	Element Name	Req	Type	Min/Max	Usage
PLB01	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Provider Identifier Use this number for the provider identifier as assigned by the payer.	M	AN	1/30	Required
PLB02	373	Date Description: Date expressed as CCYYMMDD Industry: Fiscal Period Date Use this date for the last day of the provider’s fiscal year. If the end of the provider’s fiscal year is not known by the payer, use December 31st of the current year.	M	DT	8/8	Required
PLB03	C042	Adjustment Identifier Description: To provide the category and identifying reference information for an adjustment This code is a composite data structure. The composite identifies the reason and identifying information for the adjustment dollar amount in PLB04.	M	Comp		Required
	426	Adjustment Reason Code Description: Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment	M	ID	2/2	Required