PLB Provider Level Adjustment

To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service

Position: PLB-01 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Mandatory · Min: 1 · Max: 30 · Repeat: -

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

PLB01 is the provider number assigned by the payer.

Position: PLB-02 · Element: 373 · Name: Date · Type: Date (DT) · Requirement: Mandatory · Min: 6 · Max: 6 · Repeat: -

Date (YYMMDD)

PLB02 is the last day of the provider's fiscal year.

PLB-03 C042 Adjustment Identifier Composite (composite) Mandatory

Position: 01 · Element: 426 · Name: Adjustment Reason Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 2 · Repeat: -

Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

Position: 02 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 30 · Repeat: -

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Position: PLB-04 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Mandatory · Min: 1 · Max: 15 · Repeat: -

Monetary amount

PLB04 is the adjustment amount.

PLB-05 C042 Adjustment Identifier Composite (composite) Conditional

Position: 01 · Element: 426 · Name: Adjustment Reason Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 2 · Repeat: -

Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

Position: 02 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 30 · Repeat: -

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Position: PLB-06 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Conditional · Min: 1 · Max: 15 · Repeat: -

Monetary amount

PLB06 is the adjustment amount.

PLB-07 C042 Adjustment Identifier Composite (composite) Conditional

Position: 01 · Element: 426 · Name: Adjustment Reason Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 2 · Repeat: -

Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

Position: 02 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 30 · Repeat: -

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Position: PLB-08 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Conditional · Min: 1 · Max: 15 · Repeat: -

Monetary amount

PLB08 is the adjustment amount.

PLB-09 C042 Adjustment Identifier Composite (composite) Conditional

Position: 01 · Element: 426 · Name: Adjustment Reason Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 2 · Repeat: -

Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

Position: 02 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 30 · Repeat: -

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Position: PLB-10 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Conditional · Min: 1 · Max: 15 · Repeat: -

Monetary amount

PLB10 is the adjustment amount.

PLB-11 C042 Adjustment Identifier Composite (composite) Conditional

Position: 01 · Element: 426 · Name: Adjustment Reason Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 2 · Repeat: -

Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

Position: 02 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 30 · Repeat: -

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Position: PLB-12 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Conditional · Min: 1 · Max: 15 · Repeat: -

Monetary amount

PLB12 is the adjustment amount.

PLB-13 C042 Adjustment Identifier Composite (composite) Conditional

Position: 01 · Element: 426 · Name: Adjustment Reason Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 2 · Repeat: -

Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

Position: 02 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 30 · Repeat: -

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Position: PLB-14 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Conditional · Min: 1 · Max: 15 · Repeat: -

Monetary amount

PLB14 is the adjustment amount.