Remark code N198 indicates that the claim has been flagged because the healthcare professional who provided the services (rendering provider) must have an established affiliation with the entity or individual receiving payment for those services (pay-to provider). This means that there may be an issue with the claim submission if the rendering provider's information does not match or is not properly linked to the pay-to provider's information as required by the payer's policies.
Common causes of code N198 are:
1. The rendering provider's information submitted on the claim does not match the records indicating an affiliation with the pay-to provider.
2. There is a discrepancy in the provider's enrollment details with the payer, leading to a mismatch in affiliation data.
3. The claim was submitted with an incorrect or outdated rendering provider identifier, such as an NPI (National Provider Identifier), that is not linked to the pay-to provider.
4. The payer's database has not been updated to reflect a recent change in the rendering provider's affiliation status with the pay-to provider.
5. Administrative errors in the claim submission process, such as selecting the wrong provider from a drop-down menu or entering data incorrectly.
6. The rendering provider's affiliation with the pay-to provider has ended, but the billing office was not informed or failed to update the billing system accordingly.
7. The payer's system may have a technical glitch or error that incorrectly flags the claim, even if the affiliation between the rendering and pay-to providers is accurate and current.
Ways to mitigate code N198 include ensuring that the rendering provider's information is correctly linked to the pay-to provider within the billing system. This can be achieved by regularly updating provider enrollment details and affiliations in the practice management software. Additionally, it's important to verify that the National Provider Identifier (NPI) and tax identification numbers (TINs) are accurately listed and that any changes in provider affiliations are communicated to the payer in a timely manner. Before submitting claims, conduct a pre-claim audit to check for correct provider information, and consider implementing a cross-verification system where affiliations are confirmed during the patient scheduling and registration process.
The steps to address code N198 involve verifying the affiliation between the rendering provider and the pay-to provider. First, review the contractual agreements and provider enrollment records to ensure that the rendering provider is indeed affiliated with the pay-to provider as per the payer's requirements. If the affiliation is confirmed, update the claim with the correct billing information that reflects this relationship and resubmit the claim.
If the affiliation is not in place or has lapsed, take the necessary steps to establish or renew the affiliation. This may involve completing payer-specific paperwork or updating the provider's enrollment information with the payer. Once the affiliation is established, resubmit the claim with the appropriate documentation to support the affiliation.
In cases where the claim was submitted correctly and the denial is believed to be in error, prepare and submit an appeal to the payer. Include any supporting documentation that verifies the affiliation between the rendering and pay-to providers, such as a copy of the current provider agreement or a letter from the pay-to provider confirming the relationship.
Throughout this process, maintain clear and detailed records of all communications and submissions to the payer to support any future disputes or appeals that may be necessary.