How To Fix Remark Code M380 (RARC) | Common Reasons, Next Steps & How To Avoid It

Remark Code N167 means that charges exceed the post-transplant coverage limit. This code is used to indicate that the charges for a specific medical procedure or treatment related to a transplant exceed the coverage limit set by the insurance provider. It is important for medical coders to understand this code in order to properly handle claims and ensure accurate billing.

1. Description

Remark Code N167 indicates that charges for a post-transplant procedure or treatment exceed the coverage limit set by the insurance provider. The official description states: ‘Charges exceed the post-transplant coverage limit.’ This means that the amount billed for the specific service or treatment related to a transplant is higher than what the insurance company is willing to cover.

2. Common Reasons

1. Expensive medications or therapies: Post-transplant care often involves costly medications and therapies that can quickly add up and exceed the coverage limit.
2. Unforeseen complications: Sometimes, unexpected complications may arise during the post-transplant period, leading to additional medical expenses that surpass the coverage limit.
3. Extended hospital stays: Prolonged hospital stays due to post-transplant complications or recovery can result in charges that go beyond the coverage limit.
4. Out-of-network providers: If a patient receives post-transplant care from providers who are not in the insurance network, the charges may exceed the coverage limit.

3. Next Steps

1. Review the coverage limit: Verify the coverage limit set by the insurance provider for post-transplant procedures or treatments.
2. Identify the charges that exceed the limit: Analyze the claim to determine which specific charges are exceeding the coverage limit.
3. Communicate with the insurance company: Contact the insurance company to discuss the charges and seek clarification on the coverage limit.
4. Explore alternative coverage options: If the charges consistently exceed the coverage limit, explore alternative insurance plans or programs that may provide better coverage for post-transplant care.

4. How To Avoid It

1. Verify coverage limits before treatment: Prior to initiating any post-transplant procedures or treatments, ensure that the coverage limit is understood and communicated to the patient.
2. Coordinate with the insurance company: Maintain open lines of communication with the insurance company to stay informed about coverage limits and any changes that may occur.
3. Explore pre-authorization options: For expensive procedures or treatments, consider obtaining pre-authorization from the insurance company to ensure coverage.
4. Utilize in-network providers: Whenever possible, choose healthcare providers who are in the insurance network to avoid charges that exceed the coverage limit.

5. Example Cases

1. Case 1: A claim for a post-transplant medication is denied because the cost exceeds the coverage limit, highlighting the importance of understanding and monitoring coverage limits.
2. Case 2: A claim adjustment occurs due to charges for an out-of-network provider during post-transplant care, emphasizing the need to choose in-network providers to avoid exceeding coverage limits.

Source: Remittance Advice Remark Codes