How To Fix Remark Code M766 (RARC) | Common Reasons, Next Steps & How To Avoid It

Remark Code N564 means that the patient did not meet the inclusion criteria for the demonstration project or pilot program. This code is used to indicate that the patient’s eligibility for the program was not met, resulting in denial or adjustment of the claim.

1. Description

Remark Code N564 indicates that the patient did not meet the inclusion criteria for the demonstration project or pilot program. The official description states: ‘Patient did not meet the inclusion criteria for the demonstration project or pilot program.’ This remark code is typically used when a patient’s eligibility for a specific program or study is not met, leading to claim denial or adjustment.

2. Common Reasons

1. Ineligibility for the program: The patient may not meet the specific criteria set by the demonstration project or pilot program. This could be due to age, medical history, or other factors outlined in the program guidelines.
2. Lack of required documentation: The patient may not have provided the necessary documentation to prove their eligibility for the program. This could include medical records, test results, or other supporting documents.
3. Failure to follow program guidelines: The patient may have failed to adhere to the guidelines and requirements of the demonstration project or pilot program, resulting in their ineligibility.
4. Exclusion due to prior participation: The patient may have previously participated in the program or a similar study, making them ineligible for further participation.

3. Next Steps

1. Review program guidelines: Carefully review the guidelines and criteria of the demonstration project or pilot program to ensure the patient’s eligibility.
2. Collect necessary documentation: Gather all required documentation to support the patient’s eligibility for the program. This may include medical records, test results, or other relevant documents.
3. Ensure compliance with program requirements: Educate the patient about the program guidelines and ensure they understand and follow all requirements to maintain eligibility.
4. Verify prior participation: Check the patient’s history to confirm if they have previously participated in the program or a similar study. This will help determine their eligibility for future participation.

4. How To Avoid It

1. Thoroughly screen patients: Conduct a comprehensive screening process to determine if the patient meets the inclusion criteria for the demonstration project or pilot program.
2. Request and verify documentation: Request all necessary documentation from the patient and verify its authenticity and accuracy to ensure eligibility.
3. Provide clear program guidelines: Clearly communicate the guidelines and requirements of the program to the patient, ensuring they understand what is expected of them to maintain eligibility.
4. Keep updated records: Maintain accurate and up-to-date records of the patient’s participation in the program or similar studies to avoid any potential issues with eligibility.

5. Example Cases

1. Case 1: A claim is denied because the patient’s age does not meet the age requirement specified in the demonstration project. This highlights the importance of carefully assessing the patient’s eligibility based on the program criteria.
2. Case 2: A claim adjustment occurs because the patient failed to provide the necessary medical records to prove their eligibility for the pilot program. This emphasizes the significance of collecting and verifying all required documentation.

Source: Remittance Advice Remark Codes