Remark code N133 indicates that the claim submitted includes services for which a predetermination of benefits was requested, as well as services for which payment is being requested. These services are being processed separately by the payer. This means that the payer is handling the assessment of coverage or benefits for the services needing predetermination independently from the processing of the claim for immediate reimbursement. Providers should be aware that they may receive separate communications or explanations of benefits for these services, and should manage their billing and follow-up processes accordingly.
Common causes of code N133 are:
1. Submission of a claim that includes both services that require predetermination of benefits and services that are being billed for immediate payment.
2. Incorrect claim form segmentation, leading to the mixing of predetermination requests with standard claim requests.
3. Failure to follow payer-specific guidelines for submitting predetermination requests separately from claims for payment.
4. Inadequate separation of services on the claim form, which should be processed under different timelines or payment cycles.
5. The use of incorrect procedure codes that automatically trigger a predetermination review by the payer, when such a review was not intended for all services billed.
6. Lack of clear communication or documentation to distinguish between services that are pending approval and those that are ready for immediate reimbursement.
Ways to mitigate code N133 include ensuring that predetermination requests and claims for payment are submitted with clear distinctions and appropriate documentation. It's important to verify that the predetermination request is complete and accurate before submission, and that it is not bundled with the actual claim for services. Additionally, staff should be trained to recognize the different processing requirements for predeterminations and claims, and to use the correct forms and codes for each. Regular audits of the billing process can help identify any recurring issues with predetermination requests that could lead to this code being generated. Implementing a robust tracking system can also help in monitoring the status of predeterminations and claims to ensure they are processed correctly and in a timely manner.
The steps to address code N133 involve separating the claim submission process into two distinct parts. First, submit the predetermination or preauthorization request to the payer to confirm coverage and obtain approval for the proposed services. Ensure that all necessary clinical documentation and justifications for the treatment are included to support the necessity of the services.
Once predetermination approval is received, proceed with providing the services to the patient. After the services are rendered, submit a separate claim for payment, referencing the predetermination or preauthorization number provided by the payer. This claim should include all relevant procedure codes, dates of service, and any additional information required by the payer to process the payment.
Monitor the claim status regularly and be prepared to provide any additional information if requested by the payer to facilitate the processing of the payment. By following these steps, you can effectively manage claims with code N133 and ensure that both predetermination requests and payment claims are handled efficiently.