N355Remark Code (RARC)ActiveInformational Alert
N355 Remark Code - Refund Requirement Alert
The N355 alert informs providers about exceptions to the refund requirement when a service is denied. Specifically, it outlines two scenarios where a provider may not need to issue a refund: if they were unaware of the denial risk or if they informed the patient in writing prior to the service and obtained their agreement to pay.
What This Alert Tells You
The N355 alert is not tied to a specific adjustment but serves as a reminder of the legal obligations regarding refunds following service denials. It typically accompanies denials that may require refund considerations, highlighting the need for awareness of patient communication and appeal processes.
Common Scenarios
1A provider submitted a claim for a procedure that was subsequently denied by the payer. The provider was unsure whether the service would be covered and has not informed the patient about the potential denial.
→ The N355 alert indicates that the provider may need to issue a refund unless they can prove they were unaware of the denial risk.
2A patient received a service and was advised in writing by the provider that the service might not be covered. The patient signed an agreement to pay for the service regardless of the payer's decision.
→ In this case, the N355 alert suggests that the provider may not need to refund the patient if the payer denies the service, as they fall within the exception outlined in the alert.
3After a service denial, the provider believes the payer made an incorrect determination and is considering appealing the decision.
→ The N355 alert encourages the provider to appeal the denial within 30 days, allowing them to delay the refund process until the appeal outcome is known.
What to Do
- Review the patient's file to confirm communication regarding the potential denial prior to the service.
- If applicable, prepare to submit an appeal to the payer within the specified timeframe.
- Document any agreements made with the patient regarding payment responsibility.
What to Check
- The written communication sent to the patient regarding the service and its potential denial.
- The patient's signed agreement related to the service provided.
- The denial notice from the payer for any details that may support an appeal.