Remark code N128 indicates that the amount specified is the portion of the payment allowance that was applied to services rendered before the patient's insurance coverage was in effect.
Common causes of code N128 are:
1. The service or procedure was performed before the effective date of the patient's insurance coverage.
2. The claim was submitted for a period when the patient was not covered under the insurance plan.
3. There may have been a lapse in the patient's insurance coverage at the time the healthcare service was provided.
4. The patient's policy may have specific waiting periods for certain conditions or treatments that had not yet been met.
5. The insurance plan may include a retroactive denial clause, and the service was deemed to fall within that retroactive period.
6. Incorrect or outdated patient insurance information was used when submitting the claim, leading to a mismatch with the actual coverage dates.
7. The patient's coverage was terminated, and the service date falls after the termination date.
8. The claim was not coordinated properly with other insurance if the patient has multiple coverage, resulting in an incorrect determination of the primary payer.
Ways to mitigate code N128 include implementing a robust verification process to confirm patient eligibility and coverage details before services are rendered. Ensure that your billing team is well-versed in the specifics of insurance plans, including the coverage effective dates and any waiting periods that might affect the timing of coverage. Regularly update and maintain patient insurance information in your system to avoid outdated or incorrect coverage data. Additionally, provide thorough training for front-end staff to collect accurate patient information during the pre-registration process and to communicate effectively with patients about their coverage status and potential financial responsibilities.
The steps to address code N128 involve a thorough review of the patient's insurance coverage effective dates. First, verify the date of service against the patient's insurance effective coverage period to ensure that the service date falls within the covered period. If the service date is indeed within the coverage period, gather all necessary documentation that proves this and submit an appeal to the insurer with the evidence attached.
If the service date is prior to the coverage period, check for any possible retroactive coverage that the patient may have. If retroactive coverage is available, coordinate with the insurance company to update their records and resubmit the claim.
In the absence of retroactive coverage, communicate with the patient regarding their financial responsibility for the service provided. Provide a clear explanation of the denial and the portion of the bill they are responsible for. Offer to assist the patient with a payment plan or discuss alternative financial assistance options if available. Ensure that all communication and actions taken are documented in the patient's account for future reference.