Remark code N95 indicates that the service billed is not within the scope of practice or does not align with the provider type or specialty on record. This means that the claim has been flagged because the healthcare provider's classification does not permit them to bill for the specific service they have attempted to charge. The provider will need to review the service in question and the associated billing guidelines to ensure compliance with payer requirements.
Common causes of code N95 are:
1. The provider's specialty is not authorized to perform the billed service according to payer rules.
2. The service code submitted is not within the scope of practice for the provider's designated type or specialty.
3. The claim was submitted with an incorrect provider type or specialty designation.
4. There may be restrictions in the provider's contract or participation agreement with the payer that preclude billing for the service.
5. The payer's policies or regulations may have recently changed, disallowing the provider type or specialty from billing the service.
6. The claim form may have been filled out incorrectly, leading to a mismatch between the service provided and the provider's credentials.
7. The billing staff may not be up-to-date with the payer's current guidelines regarding provider types and specialties allowed to bill for certain services.
Ways to mitigate code N95 include ensuring that the billing staff is fully aware of the provider's type and specialty limitations as per payer contracts and guidelines. Regular training should be provided to keep the billing team updated on which services can be billed by which provider types and specialties. Before submitting claims, use a pre-claim editing tool to verify that the provider's National Provider Identifier (NPI) matches the service being billed. Implement a system to flag services that are not typically covered for a provider's specialty, prompting a review before claim submission. Establish a protocol for cross-referencing the billed services with the provider's credentials to confirm eligibility for reimbursement. Additionally, maintain open communication with payers to stay informed about any changes in billing policies related to provider types and specialties.
The steps to address code N95 involve a multi-faceted approach to ensure that billing practices align with provider credentials and service qualifications. Begin by reviewing the provider's type and specialty against the services rendered to confirm whether the mismatch is accurate. If the provider is indeed qualified to perform and bill for the service, gather the necessary documentation that substantiates the provider's credentials and the service provided.
Next, update the billing records to reflect the correct provider type and specialty, if it was previously entered incorrectly. If the billing was accurate, but the denial still occurred, contact the payer to discuss the discrepancy and provide evidence of the provider's qualifications.
In cases where the provider is not qualified to bill for the service, it may be necessary to reassign the service to a provider with the appropriate type and specialty. Ensure that all future billings are conducted with the correct provider information to prevent recurring denials.
Additionally, consider implementing an internal audit process to regularly review provider credentials against billed services to minimize the risk of this issue arising in the future. Training staff on the specific billing requirements for different provider types and specialties can also help prevent such errors.