N96Remark Code (RARC)Active
N96 Remark Code - Surgical Candidacy and Therapy Requirements
The N96 remark code indicates that for the claim to be considered, the patient must demonstrate resistance to conventional therapies, which should be documented. Furthermore, the patient must qualify as a suitable candidate for surgery where implantation can be performed with anesthesia.
How It Relates to the Denial
The N96 remark code typically accompanies adjustments related to procedures requiring prior authorization or specific medical necessity criteria. It clarifies the reasons for denial or reduction in payment based on these medical necessity requirements.
Common Scenarios
1A claim was submitted for an implantable device after a patient underwent initial treatment options, but the claim was denied due to insufficient documentation.
→ The N96 remark code highlights that the payer expects evidence showing the patient tried and failed conventional therapies before considering the surgical procedure.
2A surgical procedure was billed for a patient who did not meet the criteria for prior treatments, and the remittance indicated a denial with the accompanying reason code.
→ The presence of N96 implies that the payer is looking for documentation that outlines the patient's treatment history and their candidacy for the surgery.
3A provider submitted a claim for a surgical intervention but received a partial payment, indicating the patient did not meet the necessary conditions for coverage.
→ N96 suggests that the payer requires proof of the patient's refractory status to other therapies and their suitability for the surgical procedure.
What to Do
- Provide documentation showing that the patient is refractory to conventional therapy, including behavioral, pharmacologic, and/or surgical treatments.
- Ensure that the surgical candidacy criteria are met and documented, demonstrating that implantation with anesthesia is feasible.
What to Check
- The patient's medical records for evidence of previously tried therapies and their outcomes.
- The surgical notes confirming the patient's suitability for the procedure and anesthesia.
- The claim adjustment reason code that accompanies the N96 remark for further context on the denial.