Remark code N559 is an alert that the claim isn't payable in the current service area and must be filed to the correct Payer/Plan.
Remark code N559 is an indication that the claim or service submitted is not payable because it falls outside the payer's service area. To proceed, the claim must be filed with the payer or insurance plan that is associated with the service area where the ordering physician is located.
Common causes of code N559 are:
1. The healthcare provider submitted a claim to a payer whose service area does not cover the location of the ordering physician.
2. Incorrect identification or selection of the payer during the claim submission process, leading to the claim being sent to a payer not responsible for the service area.
3. Miscommunication or lack of verification of the payer's service area in relation to the ordering physician's location prior to claim submission.
4. Administrative errors in the patient's records, such as incorrect assignment of the primary insurance plan, which does not match the service area of the ordering physician.
5. Failure to update the payer information in the healthcare provider's billing system when a patient changes their insurance plan, resulting in claims being sent to the wrong payer.
Ways to mitigate code N559 include ensuring that the billing team verifies the service area of the payer/plan relevant to the ordering physician's location before submitting claims. Implementing a robust verification process that includes checking the physician's details against the payer's service area requirements can prevent this issue. Additionally, educating your staff about the importance of accurately capturing and reviewing the ordering physician's information during the patient intake process can help avoid this error. Utilizing updated software that flags potential mismatches between service areas and ordering physicians before claim submission can also be beneficial. Lastly, establishing a routine audit of claims denied for this reason will help identify any systemic issues or training needs within your billing department to prevent future occurrences.
The steps to address code N559 involve a multi-faceted approach to ensure the claim is redirected correctly and efficiently to the appropriate payer or plan. Initially, it's crucial to verify the location of the ordering physician and confirm the service area associated with the payer or plan that should cover the claim. This may require contacting the ordering physician's office to confirm their primary service area or consulting the payer's documentation to understand their geographical coverage.
Once the correct service area and corresponding payer or plan are identified, the claim should be reprocessed with the updated information. This includes adjusting the claim's billing information to reflect the service area of the ordering physician accurately. It's also advisable to include a cover letter or note with the reprocessed claim, briefly explaining the reason for the redirection and highlighting the service area discrepancy that led to the initial denial.
To prevent future occurrences of code N559, consider implementing a verification process for the ordering physician's service area at the time of service. This could involve a quick check against a database of physicians and their associated service areas or setting up a system alert to flag services that may fall outside of the expected coverage area based on the ordering physician's location. By proactively addressing these discrepancies, healthcare providers can reduce the likelihood of similar denials and streamline the claims process for services rendered.
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