Remark code N406 indicates a service is covered only if the recipient's insurers do not offer coverage for this specific service.
Remark code N406 indicates that the service is only covered when the recipient's insurer(s) do not provide coverage for the service.
Common causes of code N406 are situations where the billing party may have inaccurately determined the patient's insurance coverage, leading to a claim for services that are actually covered by the patient's primary or secondary insurance. This can occur due to outdated or incorrect insurance information, failure to verify insurance coverage before providing services, or misinterpretation of the insurance policy's benefits. Additionally, it may result from a lack of coordination between multiple insurers when the patient has more than one insurance policy, leading to an assumption that a service is not covered when, in fact, it is.
Ways to mitigate code N406 include implementing a comprehensive insurance verification process before rendering services. This involves training front-end staff to thoroughly check each patient's insurance benefits and coverage limitations. Utilizing advanced eligibility verification software can automate and streamline this process, ensuring that coverage details are accurately captured and updated in real-time. Establishing clear communication channels with insurance providers is also crucial to clarify coverage specifics and resolve any ambiguities before service delivery. Additionally, developing a patient education program can help in informing patients about the importance of understanding their insurance policies and the potential impact on their access to certain services. This proactive approach can significantly reduce the incidence of code N406 by ensuring services are provided within the scope of the patient's insurance coverage.
The steps to address code N406 involve a multi-faceted approach to ensure that the claim is processed correctly and efficiently. Initially, verify the patient's current insurance information to confirm that no changes have occurred since the last update. If the patient has multiple insurers, coordinate benefits to determine the primary and secondary payers. In cases where the primary insurer does not cover the service, documentation proving the lack of coverage should be obtained and submitted to the secondary insurer or Medicaid, if applicable. This may include a denial letter or an Explanation of Benefits (EOB) from the primary insurer. It's crucial to review the patient's policy or contact the insurer directly to understand the specific exclusions or limitations that led to the denial of coverage. If the service is indeed not covered by any of the patient's insurers, consider appealing the decision with detailed justification for the necessity of the service, including medical records and any relevant clinical guidelines or research supporting the service's efficacy. Throughout this process, maintain clear and open communication with the patient regarding their coverage and any potential out-of-pocket costs, exploring all possible avenues for coverage or alternative funding sources if necessary.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
