N549Remark Code (RARC)ActiveInformational Alert
N549 Remark Code: Patient Out-of-Pocket Maximum Met
The N549 code indicates that the patient's calendar year out-of-pocket maximum has been met. This alert informs the provider that any further covered services for the remainder of the calendar year may not require additional cost-sharing from the patient.
What This Alert Tells You
As an informational alert, the N549 code does not accompany any specific adjustment or denial reason code. It serves to notify providers about the patient's financial responsibility status without impacting claim payments.
Common Scenarios
1A patient receives a series of treatments throughout the year and the provider sees the N549 alert on their remittance advice after the last treatment of the year.
→ The alert indicates that the patient has reached their out-of-pocket maximum, suggesting that the provider will receive full payment for any additional services rendered for the rest of the year.
2During a routine review of remittance advice, a billing specialist notices the N549 alert following a costly surgical procedure billed to a patient.
→ This alert signifies that the patient will not incur any additional out-of-pocket expenses for subsequent covered services, as they have already met their financial limit for the year.
3A provider submits multiple claims for a patient who has ongoing treatment, and the N549 alert appears on the 835 after the patient has utilized significant services.
→ The presence of this alert indicates to the provider that the patient has met their out-of-pocket maximum, meaning they will not have to collect further payments from the patient for any additional covered services.
What to Do
- Do not take any action regarding resubmission of claims based on this alert.
- Use this information to inform the patient that they have met their out-of-pocket maximum for the year.
What to Check
- Review the patient's benefit plan to confirm the out-of-pocket maximum details.
- Check the patient's claims history for services rendered throughout the calendar year.
- Verify with the payer if there are any specific conditions related to the out-of-pocket maximum that may affect future billing.