Government Programs: Interpreting the ‘PLB’ Segment on the 835 Electronic Remittance Advice (ERA)

Posted October 31, 2018

Reversals and corrections may occur when claim adjudication results have been modified from a previous claim report. The method for revision is to reverse the entire claim and resend with modified data. Provider level adjustments are reported in the Provider Level Balance (PLB) segment within the 835 ERA from Blue Cross and Blue Shield of Illinois (BCBSIL).

We’ve prepared a helpful resource to assist you with interpreting the PLB segment on 835 ERAs related to claims submitted for the following government programs members:

• Blue Cross Community Health Plans^SM
• Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM
• Blue Cross Medicare Advantage (HMO)^SM
• Blue Cross Medicare Advantage (PPO)^SM

We encourage you to refer to the Interpreting the PLB Segment on the 835 ERA - Government Programs Only document. This document provides additional details regarding adjustment codes that may appear in the PLB segment, in accordance with the requirements as specified within the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-mandated Technical Report Type 3 (TR3).* The document also includes information on PLB segment definitions and examples, as well as how to locate overpaid claims on the ERA and paper Provider Claim Summary (PCS). 

Please share this document with your practice management/hospital information system software vendor, and/or your billing service or clearinghouse, if applicable.

*The HIPAA-mandated ASC X12 Health Care Claim/Payment Advice (835) TR3 is available on the Washington Publishing Company (WPC) website at wpc-edi.com. WPC is an independent third party vendor that is solely responsible for its products and services.

References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.