N115Remark Code (RARC)Active
N115 Remark Code - Local Coverage Determination Decision
The N115 remark code indicates that the payer's decision on the claim was based on a Local Coverage Determination (LCD). This means that the item or service billed may or may not be covered under Medicare guidelines, as outlined in the relevant LCD.
How It Relates to the Denial
Typically, the N115 remark code accompanies a Claim Adjustment Reason Code that indicates a denial or reduction in payment due to coverage issues. The combination signals that the service in question was evaluated against specific local guidelines for coverage.
Common Scenarios
1A provider submits a claim for a certain diagnostic test, but the remittance shows an adjustment indicating denial based on coverage.
→ The N115 remark suggests that the denial was influenced by an LCD, meaning the test may not be covered under local guidelines.
2A claim for a durable medical equipment (DME) item is billed, and the remittance reflects a partial payment along with an adjustment for non-coverage.
→ The appearance of the N115 remark indicates that the partial payment or denial was determined based on the guidelines set forth in an LCD, affecting the item billed.
3A claim for a specific therapy service results in a denial, and the remittance includes a reason code related to medical necessity.
→ The N115 remark indicates that the decision to deny the claim was guided by an LCD, suggesting the service may not meet local criteria for coverage.
What to Do
- Review the specific Local Coverage Determination that applies to the billed service or item.
- Consider whether the service meets the criteria outlined in the LCD.
- If applicable, prepare to provide additional documentation that supports medical necessity or coverage.
What to Check
- The Local Coverage Determination policy available at www.cms.gov/mcd.
- The claim details to ensure that the service billed aligns with LCD requirements.
- Any additional notes or documentation that may support the necessity of the service or item in question.