Remark code N175 indicates that the claim has been processed but is missing approval from the review organization. This typically means that the claim requires prior authorization or a referral from a designated review entity, such as a utilization review committee or an independent review organization, and that this authorization was not included or was insufficient with the claim submission. To resolve this issue, the healthcare provider may need to obtain and submit the necessary approval documentation to the payer.
Common causes of code N175 are:
1. The claim was submitted without the necessary pre-authorization number from the review organization.
2. Documentation required by the review organization for approval was not provided or was incomplete.
3. The pre-authorization request was not submitted in a timely manner, leading to a lack of approval at the time of claim submission.
4. The provider may have failed to follow the correct procedure for obtaining review organization approval.
5. There may have been a clerical error in recording or transmitting the approval, resulting in its absence on the claim.
6. The services rendered may not match the services for which approval was granted, leading to a discrepancy and subsequent denial.
7. The approval may have expired due to the time elapsed between the authorization and the actual provision of services.
Ways to mitigate code N175 include establishing a robust pre-authorization process within your practice. Ensure that all staff members are trained on the importance of obtaining necessary approvals from review organizations before services are rendered. Implement a checklist for each patient's file that includes a step for verifying authorization status. Utilize electronic health record (EHR) systems with integrated authorization tracking features to alert staff of pending or missing approvals. Regularly audit patient files to ensure compliance with authorization requirements and address any discrepancies immediately. Develop a strong communication channel with review organizations to quickly resolve any authorization issues that may arise.
The steps to address code N175 involve verifying if prior authorization was required for the service provided and, if so, confirming whether this authorization was obtained before the service was rendered. If prior authorization was not obtained, contact the review organization to request retroactive approval, if possible. If authorization was indeed secured, ensure that the authorization number is correctly documented and resubmit the claim with the appropriate documentation attached. Additionally, review internal processes to prevent future occurrences by ensuring that staff are aware of the services that require prior authorization and that there is a system in place to obtain and track these authorizations effectively.