Remark code N758 is an adjustment notice indicating a decision based on prior authorization for healthcare providers.
Remark code N758 is an indication that the payment adjustment made to the claim is due to the decision made during the prior authorization process.
Common causes of code N758 are:
1. The service provided was not covered under the prior authorization granted.
2. The number of services or units billed exceeded the amount authorized.
3. The prior authorization number was not correctly reported on the claim.
4. The services were rendered outside the authorized period.
5. There was a mismatch between the procedure codes or diagnosis codes submitted and those approved in the prior authorization.
6. The claim was submitted for a different provider than the one authorized.
7. Incorrect patient information was provided, leading to a discrepancy with the authorized services.
8. Failure to submit necessary documentation or information required for the authorized services.
Ways to mitigate code N758 include implementing a robust pre-authorization process within your practice. This involves training your staff to always verify if a service requires prior authorization before it is provided. Utilize advanced software that flags services needing prior authorization and integrates with payers for real-time verification. Establishing a dedicated team to handle authorizations can also ensure that all necessary approvals are obtained in a timely manner, reducing the risk of adjustments based on prior authorization decisions. Regularly reviewing payer agreements and staying updated on changes in authorization requirements is crucial. Additionally, fostering strong communication channels with payers can help quickly resolve any discrepancies or misunderstandings about authorization decisions.
The steps to address code N758 involve a multi-faceted approach focusing on the prior authorization aspect of the claim. Initially, it's crucial to verify the accuracy of the prior authorization information submitted with the claim. This includes checking the authorization number, the dates of service, and ensuring that the services billed match the services authorized. If discrepancies are found, correct the claim with the accurate information and resubmit it.
If the prior authorization information was accurate but the claim was still adjusted, the next step is to contact the payer directly. Prepare to provide detailed information about the claim, the prior authorization, and any relevant documentation that supports the necessity and appropriateness of the services rendered. This may involve submitting medical records or a letter of medical necessity.
In cases where the prior authorization was not obtained before the service was provided, evaluate if an exception can be requested. Some payers allow for retroactive authorizations under specific circumstances, such as emergency services or if there was a reasonable belief that the authorization was in place.
Additionally, it's important to review internal processes for obtaining and verifying prior authorizations. This may involve training staff on the importance of accurate and timely prior authorization, implementing checks to ensure authorizations are obtained before services are rendered, and using technology to track authorization statuses.
Finally, if the adjustment is upheld by the payer, consider the appeal process. Gather all necessary documentation, including medical records, prior authorization correspondence, and any other evidence that supports the appeal. Submit the appeal according to the payer's guidelines, and monitor the appeal status closely.
Throughout this process, maintaining clear and detailed documentation is crucial. This not only supports your case in discussions with the payer but also helps identify any patterns or recurring issues that can be addressed to prevent future occurrences of code N758 adjustments.
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