Remark code N219 indicates that the payment has been adjusted because it is based on the allowed amount previously determined by another payer. This typically occurs in situations where there is coordination of benefits and the primary payer has already established an allowed amount for the service or procedure. The secondary or subsequent payer then uses this amount as a reference for their payment calculation.
Common causes of code N219 are:
1. The secondary payer has adjusted the payment based on the allowed amount determined by the primary payer, rather than calculating their own allowed amount.
2. There may have been an overpayment by the primary insurer, and the secondary insurer has reduced their payment accordingly to prevent overpayment of the claim.
3. The claim was submitted to the secondary payer with the primary payer's payment information, and the secondary payer's policy is to consider the primary's allowed amount when determining their payment.
4. The secondary payer's benefits coordination rules dictate that their payment, combined with the primary payer's payment, should not exceed the primary payer's allowed amount.
5. The Explanation of Benefits (EOB) or remittance advice from the primary payer was not properly attached or referenced, leading the secondary payer to default to the primary's allowed amount for their payment calculation.
6. The claim may have been incorrectly processed due to a misunderstanding of the coordination of benefits between the primary and secondary payers.
7. The patient's coverage under the secondary insurance plan may have specific limits or caps that are based on the primary insurance's payment, triggering the application of code N219.
Ways to mitigate code N219 include ensuring that your billing team verifies secondary insurance payment details before submitting claims. It's important to coordinate benefits accurately and understand the payment methodologies of secondary payers. Implementing a system to track primary payer payments and allowed amounts can help prevent discrepancies. Regular training for staff on coordination of benefits and payer-specific billing requirements is also crucial. Additionally, using software that automatically updates payer rules and allowed amounts can reduce the likelihood of this code being triggered. It's also beneficial to perform periodic audits of your billing processes to identify and correct any issues that could lead to code N219.
The steps to address code N219 involve a thorough review of the Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) from the previous payer to verify the allowed amount. If the amount is accurate, adjust the patient's account accordingly. If discrepancies are found, gather documentation such as the original claim, the contract terms with the payer, and any relevant payment schedules. Use this information to appeal the decision with the current payer, providing evidence to support the correct allowed amount. Ensure that your billing team communicates with the previous payer if necessary to resolve any inconsistencies and to secure the appropriate reimbursement. Keep detailed records of all communications and submissions for future reference and potential audits.