Remark code N215 indicates that when a payer is responsible for supplemental or secondary coverage, they should not mandate a claims determination or adjudication from the primary payer before making their own decision on the claim for the service in question. This means that the secondary or supplemental insurer should process the claim based on the information provided without waiting for the primary insurer's decision.
Common causes of code N215 are:
1. The secondary or supplemental insurer has incorrectly requested an Explanation of Benefits (EOB) or payment information from the primary insurer before processing a claim.
2. There may be a misunderstanding or miscommunication regarding the coordination of benefits between the primary and secondary payers.
3. The claim was submitted to the secondary payer without the necessary documentation to indicate that the primary payer's responsibility has been met or does not exist.
4. The secondary payer's claims processing system may be set up incorrectly, leading to an automated request for primary payer information even when it is not required.
5. There could be an error in the claim submission where the primary payer's adjudication was not clearly indicated, causing the secondary payer to seek additional information.
6. The healthcare provider may have failed to update the patient's insurance information, leading to confusion about the order of payers.
7. The claim form may have been filled out incorrectly, omitting the necessary details that confirm the primary payer's adjudication status.
Ways to mitigate code N215 include ensuring that your billing system is updated to recognize when a payer is supplemental or secondary and does not require primary payer adjudication information. Train your billing staff to identify these specific payer contracts and to understand the coordination of benefits rules that apply. Implement a process to review and verify the coverage order before submitting claims, and maintain clear communication with the secondary or supplemental payers to understand their specific claims processing requirements. Additionally, use electronic verification tools to confirm coverage details and document all interactions with payers regarding their claims determination policies. This proactive approach can help prevent unnecessary denials and streamline the claims submission process for services where primary payer determination is not required.
The steps to address code N215 involve reviewing the claim to ensure that it has been submitted directly to the supplemental or secondary payer without waiting for the primary payer's Explanation of Benefits (EOB) or adjudication. If the claim was submitted to the primary payer first, reprocess the claim with the secondary payer, including any necessary documentation that supports the service provided. Ensure that your billing system is set up to recognize situations where the secondary payer does not require primary payer adjudication and can process claims accordingly. Additionally, communicate with the secondary payer to clarify their specific claims processing requirements and to confirm that the claim has been received and is being processed. If the claim has been denied due to the lack of a primary payer's determination, appeal the decision with the secondary payer, providing a clear explanation and any supporting information that justifies the claim. It's also important to educate your billing staff about this specific scenario to prevent future occurrences and to streamline the claims submission process for secondary payers that do not require primary payer adjudication.