Remark code N25 indicates that the payer processing the claim is only responsible for the administrative aspects of claims payment services. This entity does not carry any financial risk or obligation for the claims it processes on behalf of the benefit plan. Essentially, the company is acting as a third-party administrator, managing the claims process without bearing the cost of the actual benefits provided.
Common causes of code N25 are:
1. The claim was submitted to an entity responsible only for administrative services, not for payment.
2. The payer identified on the claim is not the entity that assumes financial risk for the patient's benefit plan.
3. There may be a misunderstanding or miscommunication about the role of the third-party administrator (TPA) involved with the benefit plan.
4. The healthcare provider may have incorrectly directed the claim to a party that does not handle financial payments.
5. The claim may need to be redirected to the appropriate party that is responsible for the financial aspects of the patient's coverage.
Ways to mitigate code N25 include implementing a robust verification process to ensure that the correct administrative party is billed. This involves training staff to accurately identify and confirm the contracted claims payment entity before submitting claims. Additionally, maintaining updated records of all contracted administrative services providers and their specific roles and responsibilities can help prevent confusion and incorrect billing. Regular communication with the benefit plan providers to stay informed about any changes in contracted services or updates in claims processing protocols is also essential. By doing so, healthcare providers can ensure claims are directed to the appropriate entity, reducing the likelihood of receiving code N25 denials.
The steps to address code N25 involve a thorough review of the Explanation of Benefits (EOB) to ensure that the claim was processed correctly by the administrative services company. Next, verify that the services billed are covered under the patient's benefit plan. If services are covered, but the claim was denied or payment was not issued, contact the administrative services company for clarification on the denial or lack of payment. Document all communications for future reference. If the administrative services company confirms that the claim was processed correctly, but payment responsibility lies elsewhere, identify the correct party responsible for payment, which could be another insurer or the patient, and proceed to bill them accordingly. If the patient is responsible for payment, provide them with a clear statement of their financial responsibility and any necessary instructions for payment.