N915Remark Code (RARC)Active
N915 Remark Code - Predetermination Not Allowed
The N915 remark code indicates that the services billed require predetermination, but this process is not permitted under the member's plan. It supplements a claim adjustment reason code, clarifying that the payer does not allow predetermination for the services in question.
How It Relates to the Denial
The N915 remark code typically accompanies adjustment reason codes that relate to denied claims due to predetermination requirements. This combination signals that the services cannot be authorized in advance according to the member's benefits.
Common Scenarios
1A provider submits a claim for a surgical procedure that typically requires predetermination. The remittance advice returns with an adjustment indicating the claim is denied for lack of prior authorization.
→ The N915 remark code clarifies that the member’s plan does not allow predetermination for this type of service, which is why the claim was denied.
2A patient receives a series of diagnostic tests that generally need predetermination. The claim is denied, and the remittance statement includes a reason code for the adjustment along with the N915 remark code.
→ Here, the N915 remark code indicates that although predetermination is usually required, it is not permitted under the patient’s insurance plan, leading to the claim denial.
3A provider bills for a new treatment that is subject to predetermination. The payer denies the claim and includes an adjustment reason code along with the N915 remark code in the remittance advice.
→ The presence of the N915 remark code suggests that the payer's policy does not allow for predetermination for the billed services, indicating a clear reason for the denial.
What to Do
- Review the claim details to confirm whether predetermination was attempted or required.
- Discuss with the provider the implications of the member's plan regarding predetermination for future services.
- Consider resubmitting the claim without predetermination if the services are still necessary and allowed under the plan.
What to Check
- The patient's benefits document to verify coverage regarding predetermination.
- The claim submission details to ensure all required information was provided.
- The payer's policy on predetermination requirements for the services billed.