Electronic Remittance Advice (ERA) - Aetna

1 Electronic Remittance Advice (ERA) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. ( Aetna ) KR-0302-12 Aetna Provider eSolutionsSM Overpayment Recovery Codes When overpayment recovery is initiated from a provider who has ERA, specific adjustment codes are used to indicate the reason for adjusting the provider payment amount in the ERA. The following codes apply to ERAs generated for claims processed on Aetna s strategic claim system ( Aetna Claim Adjudication System, or ACAS). Overpayment Details by ERA For most claims, claim details are sent in the ERA via reversals and corrections at the time overpayment recovery is initiated.

2 When overpayment on a claim is due to considering a prior related claim, overpayment recovery is initiated immediately and the ERA carries claim details. When overpayment on a claim is due to a reason other than considering a prior related claim, claim details are sent via letter immediately but overpayment recovery initiation is delayed for the length of time specified by state regulations or contract requirements. If the provider does not return funds within the specified period of time, overpayment recovery is then initiated and the ERA carries claim details. Claim Details: Reversal & Correction in current ERA PLB: Not used Overpayment Details by Letter For a small number of overpaid claims (such as original claim paid to wrong provider, original claim paid for wrong family member), a corrected claim is sent, and details about the original claim are sent via letter immediately.

3 If the provider does not return funds within the specified period of time, overpayment recovery is initiated via a reversal without correction (because the correction was already sent). Claim Details: Claim Reversal without Correction PLB: Not used (if amount being recovered is equal to the original payment) Electronic Remittance Advice (ERA) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. ( Aetna ) KR-0302-12 If the amount being recovered is different from the original payment amount, a payment level adjustment will be created using a CS adjustment. Claim Details: Claim Reversal without Correction PLB Adjustment Code: CS PLB Adjustment Identifier: Aetna Claim ID Patient Acct # Earliest Claim Service Date PLB Adjustment Amount: Negative or Positive amount 835 Example: PLB*1234567890*20121231*CS:EA12345678000 -012345678-2012-01-01* Overpayment Adjustment Change to the Prior Balance and/or current Overpayment amount on the current payment due to reasons other than receipt of a provider refund check.

4 PLB Adjustment Code: CS PLB Adjustment Identifier: Aetna Claim ID Patient Acct # Earliest Claim Service Date PLB Adjustment Amount: Negative or Positive amount 835 Example: PLB*1234567890*20121231*CS:EA12345678000 -012345678-2012-01-01* Overpayment Refund Reduction to the Prior Balance and/or current Overpayment amount on this current payment due to receipt of a provider refund check. PLB Adjustment Code: CS PLB Adjustment Identifier: Aetna Claim ID Patient Acct # Earliest Claim Service Date PLB Adjustment Amount: Negative amount 835 Example: PLB*1234567890*20121231* CS:EA12345678000-012345678-2012-01-01* Electronic Remittance Advice (ERA) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies.

5 ( Aetna ) KR-0302-12 Overpayment Reversal Amount returned to the provider when an overpayment has been recovered by minus debit and also received from provider by a refund check. PLB Adjustment Code: CS PLB Adjustment Identifier: Aetna Claim ID Patient Acct # Earliest Claim Service Date PLB Adjustment Amount: Negative amount 835 Example: PLB*1234567890*20121231*CS:EA12345678000 -012345678-2012-01-01* Forward Balance When overpayment recovery is initiated but cannot be completed because the recovery amount exceeds the paid amount for this ERA, the provider s overpayment balance is carried forward from the current payment to a future payment. PLB Adjustment Code: FB PLB Adjustment Amount: Negative amount 835 Example: PLB*1234567890*20121231* FB* Prior Balance When overpayment recovery was initiated in a prior ERA but could not be completed because the recovery amount exceeded the paid amount for the prior ERA, the provider s overpayment balance is carried forward from the prior payment to the current payment.

6 PLB Adjustment Code: FB PLB Adjustment Identifier: Prior ERA Payment ID PLB Adjustment Amount: Positive amount 835 Example: PLB*1234567890*20121231*FB:9100001234567 89*