Recoupments on ERA - PLB Segment

Overview

In medical billing, a recoupment is the process by which a payer reclaims previously issued funds from a healthcare provider. This can occur for several reasons, not just overpayments. Recoupments are typically documented on the ERA (Electronic Remittance Advice) within the PLB (Provider-Level Balance) segment (usually located at the bottom of the ERA form) and are applied at the provider level rather than to a specific claim.

Recoupments may include, but are not limited to:

• Overpayments: Funds were mistakenly paid in excess of the correct amount.
• Duplicate Payments: A claim or service was reimbursed more than once.
• Coordination of Benefits (COB) Adjustments: Another payer was responsible for all or part of the payment.
• Retractions Due to Eligibility Errors: Services were rendered to an ineligible patient.
• Policy Retro-Termination: The patient’s coverage was retroactively canceled, invalidating payment.

When a provider does not voluntarily return the identified funds, the payer may apply the recouped amount as an offset to future payments. This adjustment is reflected at the bottom of the ERA in the PLB segment.

For example, the PLB on an ERA might display a message like:

  PROVIDER ADJ DETAILS: PLB REASON CODE FCN/OTHER IDENTIFIER HIC AMOUNT
  Overpayment Recovery (WO) XXXXXXXXXXXXXXXXXXXXXXX102.45
  

Where to Find PLB Segment Recoupments

Recoupments are not displayed in the standard claim history. Instead, they appear at the end of the ERA file in the PLB segment. The PLB segment is part of the ANSI 835 file format.

Segment Info:

• Loop: 835
• Segment: PLB

Locating Recoupments

To identify a recoupment:

1. Open the ERA file in the View ERA page.
   
2. Scroll to the bottom to locate the PLB segment.
3. Look for adjustment reason codes such as WO – Overpayment Recovery.