Remark code N196 indicates that the patient has the potential eligibility for alternative insurance coverage that may take precedence as the primary payer. Healthcare providers should investigate and determine if the patient has other insurance plans that should be billed before the current claim is processed.
Common causes of code N196 are:
1. The patient has recently become eligible for another insurance plan, such as a spouse's employer-sponsored plan, which has not yet been reported to the current insurer.
2. There is a discrepancy in the patient's insurance file indicating potential eligibility for another coverage that has not been verified.
3. The patient may have aged into Medicare eligibility, and this has not been communicated to the insurer or updated in the patient's records.
4. The patient may be eligible for coverage through a government program such as Medicaid, but the necessary documentation has not been provided or processed.
5. There is an error in the patient's insurance information, such as incorrect demographic data, leading to a false flag for additional coverage eligibility.
6. The patient has recently experienced a life event, such as job loss or divorce, that could affect their insurance status, and this information has not been updated with the current insurer.
7. The insurer's internal eligibility checking systems have identified a potential for other coverage based on data matching algorithms, but this has not been confirmed with the patient.
8. The patient may have secondary insurance coverage that has not been coordinated properly with the primary insurance, leading to confusion about which coverage is primary.
Ways to mitigate code N196 include implementing a thorough insurance verification process before rendering services. This should involve checking the patient's current coverage status and potential eligibility for other insurance programs. Staff should be trained to ask patients about any changes in their insurance situation and to document all relevant information accurately. Additionally, maintaining open communication with patients about the importance of reporting all insurance coverage can help ensure that all potential primary payers are identified before claims submission. Regularly updating and reviewing insurance information can also prevent this code from arising, as it helps to catch any new or additional coverage the patient may have obtained.
The steps to address code N196 involve verifying the patient's insurance information to identify any additional coverage they may be eligible for. Begin by contacting the patient to gather details about potential primary insurance plans they may have access to, such as through a spouse, parent, or employer. Once this information is obtained, coordinate with the other insurance provider to determine the primary payer. If the other coverage is confirmed to be primary, submit the claim to that insurer first. After processing by the primary insurer, if there are remaining charges, resubmit the claim to the secondary payer with the Explanation of Benefits (EOB) from the primary insurer. Ensure that all claims are submitted within the timely filing limits set by each payer to avoid denials due to late submissions. Keep detailed records of all communications and submissions in case further follow-up or appeals are necessary.