PLB Provider Level Adjustment

Opt
GT 1

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

Elements

PositionElementNameTypeMin/MaxRepeat
1
127
Reference IdentificationMandatoryAlphanumeric1/80AtMax 1
2
373
DateMandatoryDate8/8AtMax 1
C042Adjustment IdentifierMandatory
AtMax 1
4
782
Monetary AmountMandatoryDecimal1/18AtMax 1
C042Adjustment IdentifierRel
AtMax 1
6
782
Monetary AmountRelDecimal1/18AtMax 1
C042Adjustment IdentifierRel
AtMax 1
8
782
Monetary AmountRelDecimal1/18AtMax 1
C042Adjustment IdentifierRel
AtMax 1
10
782
Monetary AmountRelDecimal1/18AtMax 1
C042Adjustment IdentifierRel
AtMax 1
12
782
Monetary AmountRelDecimal1/18AtMax 1
C042Adjustment IdentifierRel
AtMax 1
14
782
Monetary AmountRelDecimal1/18AtMax 1

Element Details

ID127
NameReference Identification
LengthMin 1 / Max 80
Position1
RequirementMandatory