How To Fix Remark Code M1080 (RARC) | Common Reasons, Next Steps & How To Avoid It
Remark Code N885 means that the claim was not processed in accordance with the No Surprises Act cost-sharing or out-of-network payment requirements. This code is used when the payer disagrees with the determination that these requirements apply. It is important to understand the reasons behind this disagreement and to follow the appropriate appeals process to address the adverse determination.
1. Description
Remark Code N885 indicates that the claim was not processed in accordance with the No Surprises Act cost-sharing or out-of-network payment requirements. The official description states: ‘Alert: This claim was not processed in accordance with the No Surprises Act cost-sharing or out-of-network payment requirements. The payer disagrees with your determination that those requirements apply. You may contact the payer to find out why it disagrees. You may appeal this adverse determination on behalf of the patient through the payer’s internal appeals and external review processes.’
This remark code serves as an alert to healthcare providers that the payer disagrees with their determination regarding the application of cost-sharing or out-of-network payment requirements. It is crucial to understand the reasons behind this disagreement and to take appropriate action to address the adverse determination.
2. Common Reasons
- Disagreement on the application of cost-sharing requirements: The payer may believe that the cost-sharing requirements of the No Surprises Act do not apply to the specific claim. This could be due to differences in interpretation or understanding of the regulations.
- Disagreement on the application of out-of-network payment requirements: The payer may disagree with the determination that the claim should be processed as an out-of-network payment. This could be based on their assessment of network participation or other contractual agreements.
3. Next Steps
- Contact the payer to understand the disagreement: It is important to reach out to the payer to gain clarity on their reasons for disagreeing with the determination. This communication can help identify any misunderstandings or provide additional information to support the original determination.
- Appeal the adverse determination: If the healthcare provider believes that the original determination was correct, they can initiate the appeals process on behalf of the patient. This typically involves submitting a formal appeal through the payer’s internal appeals and external review processes.
4. How To Avoid It
- Ensure a thorough understanding of the No Surprises Act requirements: Healthcare providers should familiarize themselves with the specific cost-sharing and out-of-network payment requirements outlined in the No Surprises Act. This knowledge can help in making accurate determinations and avoiding disagreements with payers.
- Maintain clear documentation and communication: It is essential to document all relevant information related to cost-sharing and out-of-network determinations. Clear and concise communication with payers can help prevent misunderstandings and facilitate smoother claims processing.
- Stay updated on payer policies and guidelines: Payer policies and guidelines regarding cost-sharing and out-of-network payments may evolve over time. Healthcare providers should stay informed about any changes to ensure compliance and accurate claim submissions.
5. Example Cases
- Case 1: A claim for an out-of-network service is denied by the payer, stating that the No Surprises Act requirements do not apply. The healthcare provider contacts the payer to understand the disagreement and discovers that the payer had incorrect information about the provider’s network participation. The provider appeals the adverse determination and provides evidence of their out-of-network status.
- Case 2: A claim for a cost-sharing service is adjusted by the payer, reducing the patient’s responsibility. The healthcare provider believes that the cost-sharing requirements were correctly applied and contacts the payer to understand the disagreement. After discussing the details, the provider realizes that there was an error in the original determination and submits a corrected claim.
Source: Remittance Advice Remark Codes
