SYNTHETIC PAYER COMPANION GUIDE SUMMARY

This file records how each payer in this folder describes its own provider-level adjustment
semantics. The codes do not mean the same thing across payers, and that conflict is real.

Atlas Health (Commercial)
  Reason codes this payer treats as a recoupment: WO, FB, 72
  Companion guide follows the UnitedHealthcare and BCBS of Texas reading: forward balance is overpayment linked and PLB03-2 carries the trace of the prior remittance.
  Appeal or dispute window: 180 days. Basis: Contract exhibit C, provider dispute resolution
  Timely filing limit: 90 days from the date of service.

Cedar Blue (Commercial)
  Reason codes this payer treats as a recoupment: WO, FB
  Companion guide states forward balance segments do not reference the individual claim control number and that PLB03-2 carries the trace or check number of the remittance holding the overpayment detail.
  Appeal or dispute window: 180 days. Basis: Contract exhibit C, provider appeal process
  Timely filing limit: 120 days from the date of service.

Harbor Assurance (Commercial)
  Reason codes this payer treats as a recoupment: WO, FB, CS
  Companion guide treats forward balance as overpayment linked and recycles a single PLB03-2 trace across several cycles until the balance clears.
  Appeal or dispute window: 120 days. Basis: Contract exhibit C, reconsideration window
  Timely filing limit: 90 days from the date of service.

Nova Commercial (Commercial)
  Reason codes this payer treats as a recoupment: WO, FB
  Companion guide treats forward balance as overpayment linked, with PLB03-2 referencing the prior remittance trace.
  Appeal or dispute window: 150 days. Basis: Contract exhibit C, provider dispute resolution
  Timely filing limit: 90 days from the date of service.

Northwind Medicare Advantage (Medicare Advantage)
  Reason codes this payer treats as a recoupment: WO, FB
  Companion guide treats forward balance as overpayment linked and directs the provider to the remittance named in PLB03-2 for the overpayment detail.
  Appeal or dispute window: 65 days. Basis: Medicare Advantage: 65 days from the date on the organization determination notice
  Timely filing limit: 365 days from the date of service.

Summit Advantage Dual (Medicare Advantage)
  Reason codes this payer treats as a recoupment: WO, FB
  Companion guide treats forward balance as overpayment linked.
  Appeal or dispute window: 65 days. Basis: Medicare Advantage: 65 days from the date on the organization determination notice
  Timely filing limit: 365 days from the date of service.

Traditional Medicare (Traditional Medicare)
  Reason codes this payer treats as a recoupment: WO
  Contractor guidance states that a forward balance does not represent a recoupment and that recoupments are identified with PLB reason code WO. FB rows from this payer carry a balance forward, not an overpayment.
  Appeal or dispute window: 120 days. Basis: Original Medicare: 120 days for redetermination
  Timely filing limit: 365 days from the date of service.

KNOWN INDUSTRY CONFLICT, ENCODED DELIBERATELY
One Medicare contractor states that a forward balance does not represent a recoupment and that
recoupments are identified with reason code WO. Two large commercial payers describe forward
balance as overpayment linked. Both readings are present in this folder. A platform must read
these semantics from the payer profile rather than hard-coding one global mapping.

PLB03-2, THE ADJUSTMENT IDENTIFIER
A provider-level adjustment does not reference the claim control number of the overpaid claim.
The adjustment identifier carries the trace or check number of the remittance that holds the
overpayment detail. Tracing a takeback back to a claim is therefore a join from a current
remittance file to a historical one, across time, and never a lookup inside one file.
