Covered in this document:
Provider Level Adjustments
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Adjustment Code: WO – Overpayment Recovery
Adjustment Code: 72 – Authorized Return Adjustment Code: CS – Adjustment Adjustment Code: FB – Forwarding Balance Adjustment Code: LE - IRS Tax Levy
Adjustment Code: CS - State Local Garnishment
Complex Forward Balance Examples
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Provider Level Adjustments
Provider Level Adjustments appear in the PLB segment in the 835 electronic remittance advices. The
adjustments are not always associated with a claim in the same 835, but are needed to balance the
835 at the transaction (check) level. The adjustments will increase the payment when a negative
money amount is returned, or decrease the payment when a positive money amount is returned.
The following information pertains to the content returned in the PLB for Overpayment and Recovery
processes and Garnishment/Levy. Further details for these and other PLB qualifiers and their usage
may be found in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3).
Adjustment Code: WO – Overpayment Recovery
Reference Number: Patient Account Number + 1st Date of Service + Claim Number
Used when:
 A corrected and reversed claim record appears in the 835 and the monies are not immediately
recovered, the PLB with a WO will be present with a negative money value. These monies will be
recovered in a future 835.
 A previous overpayment is recovered. Monies will be expressed as a positive value.
 Acknowledging a refund sent by the provider for an overpayment notification. The WO with a
positive money value will be offset by a 72 with a negative money value.
Example: PLB*123456789*20141231*WO:PTACCT#CCYYMMDD CLAIM#*-37.5~
Adjustment Code: 72 – Authorized Return
Reference Number: Patient Account Number + 1st Date of Service + Claim Number
Used when:
 Acknowledging a refund sent by the provider for an overpayment notification. The WO with a
positive money value will be offset by a 72 with a negative money value.
Example: PLB*123456789*20141231*WO:PTACCT#CCYYMMDD
CLAIM#*25*72:PTACCT#CCYYMMDD CLAIM#*-25~
Adjustment Code: CS - Adjustment
Reference Number: Patient Account Number + 1st Date of Service + Claim Number
Used when:
 A refund received from a provider triggers a previously paid claim to adjust. A corrected and
reversed claim record appears in the 835 and the refunded monies appear as a positive money
value in the PLB with a CS qualifier.
Example: PLB*123456789*20141231*CS:PTACCT# CCYYMMDD CLAIM#*100~
Adjustment Code: FB – Forwarding Balance
Reference Number: Current Check # (TRN02) value
Used when:
 An overpayment can’t be recovered in full resulting in a forwarding balance to be recovered from
a future payment.
 An existing forwarding balance can’t be recovered in full resulting in a new forwarding balance.
The TRN02 values will be as defined in the X12 Standards for Electronic Data Interchange
Technical Report Type 3 (TR3).
Example: PLB*123456789*20141231*FB:Check#*-37.5~
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Adjustment Code: LE – IRS Tax Levy
Reference Number: IRS Tax Levy 668A or 668W – cust svc phone number
Used when:
 Monies will be expressed as a positive value in the PLB04
Example: PLB*123456789*20161231*LE* Tax Levy 668A or 668W - cust svc 5134751328*-50.52~
Adjustment Code: CS – State Local Garnishment
Reference Number: State Local Garnishment – cust svc phone number
Used when:
 Monies will be expressed as a positive value in the PLB04
Example: PLB*123456789*20161231*CS*State Local Garnishment - cust svc 5134751328*-70.25~
Complex Forward Balance Examples
835 Electronic Remittance Advice PLB Segment:
The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 has specific rules for
reporting overpayment recovery in the 835. The following information should be referenced to
understand the formatting of the PLB segments of the 835 for recoupment of funds and when forward
balance situations occur.
The following applies in situations where the recoupment will occur at the time a reversed and
corrected claim record populates the 835. When the adjustment is less than the original paid amount,
the difference will be subtracted from the check. When the monies can’t be recovered in full, a
forwarding balance (FB) is created in the PLB segment. Per the guide, the FB reference ID must be the
current TRN02 (check number) value.
The monies unable to be recovered will be identified as a forwarding balance (FB) with the monies
expressed as a negative.
PLB*9999999999*20141231*FB|TRN02CheckA*-100
When the monies can be recovered from future payment, the forwarding balance (FB) will be returned
with the monies expressed as a positive. (To identify what claims are associated to the PLB where
TRN02CheckA is referenced, refer back to the original 835 where TRN02CheckA first occurred.)
PLB*9999999999*20141231*FB|TRN02CheckA*100
If forwarding balance (FB) monies are unable to be recovered in full, a new forwarding balance (FB) will
be created with the new balance. (To identify what claims are associated to the PLB where
TRN02CheckA and TRN02CheckB are referenced, refer back to the original 835 where TRN02CheckA
first occurred.
PLB*9999999999*20141231*FB|TRN02CheckA*100
PLB*9999999999*20141231*FB|TRN02CheckB*-50
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Additional Complex Forward Balance Examples
Multiple days where claims were adjusted and negative balances occurred in different 835 ERA’s.
Day 1: Check A
The provider had previously received an 835 with a correction and reversal where the amount owed
was $100. The remit that generated the reversal and correction only had funds available with the check
to satisfy $62.50. The FB generated in that remit was for -37.50. A subsequent remit is now being
generated and now $37.50 can be used to satisfy the forward balance left in full.
Day 2: Check B
The provider had previously received an 835 with a correction and reversal where the amount owed
was $200. The remit that generated the reversal and correction only had funds available with the check
to satisfy $75.00. The FB generated in that remit was for -125.00. A subsequent remit is now being
generated and now $125.00 can be used to satisfy the forward balance left in full
Day 3: Check C
The provider had previously received an 835 with a correction and reversal where the amount owed
was $300. The remit that generated the reversal and correction only had no funds available to satisfy
$300.00. The FB generated in that remit was for -300.00. A subsequent remit is now being generated
and now $200 can be used to satisfy and will create a new FB for -100.00
First initial Remittance where FB occurred:
Day1: Check A
Provider number = 1234
Overpayment = 100.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02checkA
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKA*-37.5~
Day 2: Check B
Provider number = 1234
Overpayment = 200.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02checkB
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKB*-125.00~
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Day 3: Check C
Provider number = 1234
Overpayment = 300.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02checkC
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKC*-300.00~
DAY 4: Check D
Second subsequent remittance (different day/check/EFT):
TRN02 value – TRN02checkD
Balance yet to be satisfied is $37.50, 125.00 and 300.00 = 462.50
The remittance only has sufficient funds to offset $237.50 (CheckA 37.50 and Check B 125.00 and
check C 200.00) with balance left of 100.00
The remittance would ONLY have the following:
PLB*1234*20011231*FB: TRN02CHECKA*37.50*~
PLB*1234*20011231*FB: TRN02CHECKB*125*~
PLB*1234*20011231*FB: TRN02CHECKC*300*FB: TRN02CHECKD*-100~
Create Date 02/25/2014
Revised Date 06/13/2016
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