Remark code N36 indicates that the claim submitted to the secondary or tertiary payer cannot be processed until it has been adjudicated by the primary insurer according to their specific processing guidelines and requirements. The healthcare provider must ensure that all necessary steps have been taken with the primary payer before the claim can be reviewed for payment by the subsequent payer.
Common causes of code N36 are:
1. The primary insurance has not yet processed the claim, and secondary or tertiary payers require evidence of this processing before they will consider payment.
2. The claim was submitted to the secondary or tertiary payer before being submitted to the primary payer.
3. The Explanation of Benefits (EOB) or remittance advice from the primary payer was not included with the claim submission to the secondary or tertiary payer.
4. The claim does not include necessary information or documentation that the primary payer requires for processing, such as prior authorization, referral forms, or proof of medical necessity.
5. The claim was denied by the primary payer for reasons that must be resolved before the secondary or tertiary payer can process the claim, such as service not covered, lack of pre-certification, or incorrect coding.
6. The primary payer's payment information, such as the amount paid or patient responsibility, was not accurately reported to the secondary or tertiary payer.
7. The claim was submitted to the secondary or tertiary payer with incorrect primary payer information, leading to confusion or rejection of the claim.
8. There may be coordination of benefits issues that need to be clarified between the primary and secondary payers before the claim can be processed further.
Ways to mitigate code N36 include ensuring that all claims are submitted to the primary payer with accurate and complete information in accordance with their specific billing guidelines. Before submission, verify the patient's coverage and benefits, double-check that the correct primary insurance information is on file, and that the claim form includes all necessary data such as provider identifiers, diagnosis codes, and procedure codes that align with the primary payer's requirements. Regularly train staff on updates to the primary payer's policies and conduct periodic audits of claim submissions to identify and correct any discrepancies that could lead to this remark code. Implementing a robust claim scrubbing process that checks for errors prior to submission can also help in preventing code N36.
The steps to address code N36 involve first verifying the primary insurance details and confirming that the claim was filed correctly with the primary payer. Ensure that all necessary information, such as policy numbers, dates of service, and procedure codes, are accurate and complete. If the primary payer has denied the claim, review the denial reason, make any necessary corrections, and resubmit the claim to the primary payer. Once the primary payer has processed the claim, obtain the Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) that indicates the payment details and any patient responsibility. Attach this documentation to the claim when submitting it to the secondary payer to demonstrate that the primary payer's processing requirements have been met. If the claim has already been processed by the primary payer but this was not reflected in the initial submission to the secondary payer, resubmit the claim to the secondary payer with the appropriate EOB or ERA attached. It's also important to check for any specific coordination of benefits (COB) clauses that might affect how the claim should be processed by the secondary payer.