Remark code N536 is an explanation that the prior payer's patient responsibility decision remains unchanged, allowing collection for uncovered services.
Remark code N536 is an indication that the current payer acknowledges the determination of patient responsibility made by the prior payer and will not alter it. This means that the healthcare provider is permitted to collect the specified patient responsibility amount for services that are not covered by the current payer.
Common causes of code N536 are:
1. The service provided is not covered under the patient's current insurance plan with the secondary payer.
2. Incorrect or incomplete information was submitted regarding the primary payer's adjudication, leading the secondary payer to uphold the primary payer's determination of patient responsibility.
3. The claim was submitted to the secondary insurer without proper documentation or explanation of benefits (EOB) from the primary insurer, resulting in the secondary insurer deferring to the primary insurer's decision.
4. The service falls under an exclusion or limitation in the patient's policy with the secondary insurance, aligning with the primary payer's assessment of patient responsibility.
5. There may have been a misunderstanding or misclassification of the service provided, causing both primary and secondary insurers to deem it as non-covered.
Ways to mitigate code N536 include implementing a robust verification process for patient coverage before services are rendered. This involves confirming the specifics of the patient's insurance plan, including what services are covered and to what extent. Training staff to understand the nuances of various insurance plans can also help in identifying services that may not be covered. Additionally, maintaining open communication with patients about potential financial responsibilities for services that might not be covered by their insurance can prevent surprises and disputes. Implementing a system to regularly update insurance coverage information and staying informed about common non-covered services across different insurers can further reduce the occurrence of this code.
The steps to address code N536 involve a multi-faceted approach to ensure that the healthcare provider can effectively manage and collect the patient's responsibility as indicated by the prior payer. Firstly, it's crucial to update the patient's account to reflect the specific details of the non-coverage as indicated by this code. This includes documenting the service that was not covered and the amount determined as the patient's responsibility by the prior payer.
Next, initiate communication with the patient to inform them of the non-coverage decision and their financial responsibility. This communication should be clear, concise, and compassionate, providing the patient with a detailed explanation of the charges and the reasons for the non-coverage. It's also beneficial to offer to assist the patient in understanding their insurance benefits and to answer any questions they may have regarding their responsibility.
Following the patient communication, set up a payment plan or discuss other financial arrangements if the patient indicates an inability to pay the full amount immediately. Offering flexible payment options can significantly increase the likelihood of collecting the owed amount while maintaining a positive relationship with the patient.
Additionally, review the claim and the services provided to ensure that all coding was accurate and that no alternative billing options are available that could potentially be covered by the insurance. If any discrepancies are found or if there are services that could be re-coded for potential coverage, submit a corrected claim to the insurance for reconsideration.
Lastly, ensure that your billing team is trained to handle similar situations and is familiar with the process of addressing code N536. Regular training and updates on handling specific remark codes can improve the efficiency and effectiveness of your revenue cycle management process.
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