N405Remark Code (RARC)Active
N405 Remark Code - Service Coverage Conditions
The N405 remark code indicates that the billed service is only covered when the donor's insurance does not provide coverage for that service. This means the payer is denying the claim because the donor's insurer has coverage that applies to the service in question.
How It Relates to the Denial
The N405 remark typically accompanies a Claim Adjustment Reason Code that indicates a denial based on coverage issues related to services provided to a donor. It clarifies that coverage is contingent upon the donor's insurer not covering the service.
Common Scenarios
1A hospital bills for a transplant procedure performed on a patient who is a donor. The claim is returned with a denial indicating coverage issues.
→ The N405 remark suggests that the claim is denied because the donor's insurance does cover the transplant procedure, which means the billed service is not eligible for coverage under the current plan.
2A medical facility submits a claim for a follow-up service related to a donor organ transplant. The claim is denied, citing that the service is not covered.
→ With the N405 remark, the payer is indicating that the follow-up service is only covered if the donor's insurance does not cover it, and since it does, the claim is denied.
3A physician bills for a service provided to a donor, and the remittance advice includes a denial for that service with the N405 remark.
→ The presence of the N405 remark means the payer expects the physician to verify whether the donor's insurer provides coverage for the service before resubmitting the claim.
What to Do
- Verify the donor's insurance coverage for the service billed.
- If the donor's insurer does not cover the service, consider resubmitting the claim with appropriate documentation.
- Ensure that any required coordination of benefits information is included.
What to Check
- The donor's insurance policy documents regarding coverage for the billed service.
- The claim field that indicates the relationship of the patient to the insured (donor status).
- Any previous remittance advice that may show prior coverage decisions from the donor's insurer.