Remark code N172 indicates that the patient is not responsible for payment of the denied or adjusted charges related to receiving an updated service or item. This means that the healthcare provider cannot bill the patient for the specified charges, and the financial liability does not fall on the patient for the services or items referenced in the claim adjustment.
Common causes of code N172 are:
1. The service or item provided was updated after the original submission and the patient's insurance plan does not cover the updated service or item.
2. The healthcare provider may have billed for a service or item that was replaced or revised, and the payer determined that the patient is not responsible for the costs associated with the updated version.
3. There may have been an error in coding or billing where an outdated or incorrect service/item was initially reported, and upon correction, the patient was deemed not liable for the charge difference.
4. The payer's policy might include a provision that protects the patient from charges resulting from the provider's administrative updates or corrections to a service or item.
5. The claim adjustment could be due to a contractual agreement between the payer and the provider that stipulates the patient is held harmless for certain updates to services or items.
Ways to mitigate code N172 include implementing a robust verification process to ensure that all services and items provided are covered under the patient's current insurance plan. This involves regularly updating and confirming the patient's insurance information, including any changes in coverage or policy updates. Additionally, staff should be trained to understand the nuances of insurance plans and to identify services that may require prior authorization or are subject to specific coverage limitations.
It's also important to establish clear communication channels with insurance providers to stay informed about any updates or changes in coverage that could affect the patient's liability. By proactively managing these aspects, healthcare providers can reduce the likelihood of services or items being denied or adjusted due to coverage updates, thereby preventing the occurrence of code N172.
The steps to address code N172 involve a thorough review of the claim to understand why the denial or adjustment occurred. First, verify that the service or item provided was indeed updated and that the update is accurately reflected in the claim. Next, check the patient's eligibility and benefits to ensure that the service or item is covered under their current plan. If the denial is due to an error in coding or billing, correct the information and resubmit the claim.
If the update to the service or item was not intended or necessary, communicate with the clinical team to confirm the medical necessity and appropriateness of the service. Documentation should be gathered to support the claim, including medical records and physician notes that justify the update.
In the case that the denial is valid and the patient is truly not liable, adjust the patient's account to remove any charges they should not be responsible for. Ensure that the billing system is updated to reflect the adjustment and that any statements sent to the patient are accurate.
Lastly, if the denial is due to payer policy regarding updates to services or items, consider reaching out to the payer for more information or to negotiate coverage. Keep detailed records of all communications and actions taken to resolve the issue for future reference and potential audits.