Remark code N5 indicates that the Explanation of Benefits (EOB) has been received from a previous payer, but the claim in question is not found on file. This suggests that there may be a discrepancy in the claim submission process or record-keeping, and further investigation is needed to reconcile the issue and proceed with the claim adjudication process.
Common causes of code N5 are:
1. The Explanation of Benefits (EOB) from the secondary or tertiary payer was received, but the primary payer's claim information is missing or was not submitted.
2. There may have been a lapse in the coordination of benefits, leading to the secondary payer not having a record of the primary payer's adjudication.
3. The claim could have been submitted to the secondary payer without first being processed by the primary payer, which is typically required.
4. The claim may have been lost or not properly filed by the primary payer, resulting in the secondary payer not having the necessary information to process the claim.
5. Incorrect or incomplete claim submission to the primary payer could have led to the claim being rejected or not recognized, and therefore not on file with the secondary payer.
6. There may be a mismatch in patient identifiers or claim numbers between what was submitted to the primary and secondary payers, causing the secondary payer to be unable to match the EOB to an existing claim.
7. Timing issues, such as the secondary payer receiving the EOB before the primary payer's claim processing is completed, could result in the claim not being recognized as on file.
Ways to mitigate code N5 include ensuring that the Explanation of Benefits (EOB) from the previous payer is attached to the claim before submission. It's important to verify that the claim has been filed with the correct payer and that all necessary information, including the EOB, is included in the claim package. Additionally, maintaining organized records of all EOBs and claims submitted can help prevent this issue by allowing for quick reference and confirmation of claim status. Regular follow-ups on the claim's progress can also help identify and address any issues promptly. Implementing a system that checks for the presence of an EOB before allowing a claim to move forward in the billing process can further reduce the likelihood of receiving code N5.
The steps to address code N5 involve first verifying the accuracy of the claim submission to the previous payer. Ensure that the claim was indeed submitted and that all necessary information, including payer identification and patient details, was accurate and complete. If the claim was submitted correctly, obtain a copy of the Explanation of Benefits (EOB) from the previous payer and review it for any additional information or instructions.
Next, if the claim is not found on file with the previous payer, contact their customer service to inquire about the claim's status. Provide them with the claim number, date of service, and patient information to facilitate the search. If the claim was lost or not processed, resubmit the claim with any required documentation as per the previous payer's guidelines.
If the claim was processed by the previous payer, but the current payer does not have it on file, forward the EOB along with a cover letter explaining the situation to the current payer. Ensure that the current claim submission includes all necessary information, such as the correct billing codes, patient demographics, and the previous payer's payment details or denial codes if applicable.
Document all communications and actions taken to resolve the issue for future reference and follow-up as necessary until the claim is acknowledged and processed by the current payer.