N425Remark Code (RARC)Active
N425 Remark Code - Statutorily Excluded Service Explanation
The N425 remark code indicates that the service billed is statutorily excluded from coverage, meaning it is not reimbursable under the payer's policies due to legal or regulatory reasons. This remark provides additional context to the adjustment already described by the accompanying reason code, clarifying why the claim was denied or adjusted.
How It Relates to the Denial
The N425 code typically accompanies adjustment reason codes that indicate a service is not covered or is ineligible for payment. This combination signals to the biller that the service in question is excluded from reimbursement due to statutory regulations.
Common Scenarios
1A provider submitted a claim for a specific procedure that is known to be excluded under Medicare regulations. The remittance shows a denial with an accompanying reason code indicating non-coverage.
→ The N425 remark code confirms that the procedure is not covered due to statutory exclusions, reinforcing the denial indicated by the reason code.
2A claim for durable medical equipment was submitted, but the remittance returned an adjustment indicating that the item is not payable. The accompanying N425 remark code appears on the remittance advice.
→ This means the durable medical equipment is considered statutorily excluded, and the payer is reinforcing that no payment will be made for this item.
3A claim for a cosmetic procedure was submitted, and the remittance response includes a reason code for denial alongside the N425 remark code.
→ In this case, the N425 remark indicates the cosmetic procedure is excluded from coverage due to statutory provisions, aligning with the denial reason.
What to Do
- Review the claim details to confirm the service is indeed statutorily excluded from coverage.
- Do not resubmit the claim if the service is confirmed as excluded; payment will not be made based on statutory guidelines.
- Consider discussing alternative services that may be covered under the payer's policy with the patient.
What to Check
- The payer's policy documents to understand the list of statutorily excluded services.
- The eligibility response to verify coverage limitations for the specific service.
- The claim submission details to ensure accurate coding and billing practices were followed.