Remark code N428 is an explanation for services not covered at the specified location.
Remark code N428 indicates that the service provided is not covered by the insurer when it is performed in the current location or setting.
Common causes of code N428 are:
1. The procedure or service was performed in a setting that is not authorized for reimbursement by the payer for this specific service.
2. Incorrect place of service code entered on the claim, not aligning with the payer's policy for the billed service.
3. The provider's facility type does not match the requirements set by the insurance plan for coverage of the performed service.
4. Lack of a necessary modifier indicating that the service was performed in an exception setting allowed by the payer.
5. The service is covered only when performed in specific facilities, such as a hospital or ambulatory surgical center, and was performed elsewhere.
Ways to mitigate code N428 include ensuring that the services provided are aligned with the location requirements specified by the payer. Before scheduling procedures or services, verify the payer's place of service (POS) policies to confirm that the location is approved for the specific service being rendered. Implement a pre-authorization process that includes a check for place of service compatibility. Additionally, educate both scheduling and billing staff on the importance of accurate POS coding and maintain an updated list of services along with their approved locations according to each payer's guidelines. Regular audits of billing and coding practices can also help identify and rectify any discrepancies related to place of service to prevent this issue from occurring.
The steps to address code N428 involve a multi-faceted approach focusing on both immediate resolution and long-term prevention. Initially, review the claim to verify the place of service (POS) code accuracy. If the POS was incorrectly reported, correct the code and resubmit the claim. In cases where the POS is accurate but not covered, consider if the service can be legitimately billed under a different, covered POS based on the patient's treatment plan and medical necessity. If so, coordinate with the healthcare provider to adjust the treatment setting accordingly and resubmit the claim with the appropriate documentation supporting the medical necessity for the change in POS.
Simultaneously, enhance your billing team's training on POS codes and their impact on claim acceptance to prevent future occurrences of N428. This includes creating a quick-reference guide that outlines services with POS restrictions and integrating POS verification checks into your claim submission process. Additionally, engage in regular audits of claims denied for POS issues to identify patterns or common errors, allowing for targeted improvements in your billing practices.
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