Remark code N174 indicates that the service, procedure, equipment, or bed in question is not covered under the patient's current insurance plan. Despite the lack of coverage, the patient's financial responsibility is confined to the specific adjustment amounts categorized under the 'PR' (Patient Responsibility) group. This means that the patient is only liable for the costs that have been outlined as their responsibility, and not for the full cost of the non-covered services.
Common causes of code N174 are:
1. The service, procedure, equipment, or bed provided is not included in the patient's insurance plan benefits.
2. The healthcare provider may have incorrectly coded the service or procedure, leading to a mismatch with covered benefits.
3. The service or procedure might be considered experimental or investigational by the insurance plan.
4. There may be a lack of medical necessity as determined by the insurance company's guidelines.
5. The claim could include services or equipment that are deemed luxury or convenience items, which are typically not covered.
6. The patient's policy might have specific exclusions that apply to the service or equipment billed.
7. The service could be related to a pre-existing condition for which there is a waiting period before coverage starts.
8. The provider may not have obtained the required pre-authorization or referral for the service or equipment provided.
Ways to mitigate code N174 include ensuring that services, procedures, equipment, or bed types are verified for coverage under the patient's insurance plan before they are provided. This can be achieved by implementing a robust pre-authorization process where eligibility and benefits are confirmed with the payer. Additionally, maintaining an updated database of payer coverage policies and regularly training staff on these policies can help prevent the provision of non-covered services. It's also important to have a clear communication channel with patients to inform them of potential non-covered services and their financial responsibilities. Regular audits of billing and coding practices can help identify patterns that may lead to N174 denials, allowing for corrective actions to be taken.
The steps to address code N174 involve a multi-faceted approach to ensure proper handling and resolution. Firstly, review the patient's insurance policy to confirm the non-coverage of the service or item in question. Next, examine the claim and any accompanying documentation to verify that the service was correctly coded and that no errors were made that could have led to the denial.
If the service is indeed non-covered, update the patient account to reflect the adjustment amount indicated under the 'PR' (Patient Responsibility) group. Communicate with the patient to inform them of their financial responsibility, providing a clear explanation of the non-covered service and the resulting charges.
In parallel, explore alternative billing options, such as checking if the service can be covered under a different code or if there is a possibility to appeal the decision based on medical necessity or other extenuating circumstances. If an appeal is viable, gather the necessary documentation and submit the appeal according to the payer's guidelines.
Lastly, use this experience to update your billing practices by ensuring that future claims for similar services are pre-verified for coverage to prevent recurring denials and to maintain a streamlined revenue cycle.