N536Remark Code (RARC)Active
N536 Remark Code - Patient Responsibility Not Changed
The N536 remark code indicates that the payer is not altering the previous payer's decision regarding the patient's financial responsibility for the service billed. Essentially, this means the service is not covered by the current payer, and the patient is still responsible for payment as determined by the prior payer.
How It Relates to the Denial
The N536 remark typically accompanies a Claim Adjustment Reason Code that explains a denial or adjustment related to patient responsibility. This combination signals that while the claim was not covered, the payer acknowledges the patient's financial obligation as per the previous determination.
Common Scenarios
1A provider submits a claim for a procedure that was previously billed to another payer, which denied it as not covered. The remittance advice shows the N536 remark along with a reason code indicating the service is not covered.
→ In this case, the N536 remark confirms that the current payer agrees with the prior payer's determination that the service is not covered and reinforces that the patient remains responsible for the charge.
2A claim for a diagnostic test is denied by a secondary payer with a reason code indicating non-coverage. The remittance includes the N536 remark stating that the prior payer's decision on patient responsibility stands.
→ Here, the N536 remark means the secondary payer is upholding the initial decision, indicating to the provider that they can still collect from the patient for the service rendered.
3A provider receives a remittance for a surgical procedure where the primary payer denied the claim due to lack of coverage. The remittance includes the N536 remark, suggesting the procedure is not covered by the current payer either.
→ The N536 remark in this scenario communicates that the current payer will not cover the procedure and that the patient is accountable for the costs as determined by the primary payer.
What to Do
- Review the patient's prior payer's determination regarding service coverage to understand the patient's financial responsibility.
- Consider reaching out to the patient to discuss the outstanding balance based on the prior payer's decision.
- Do not resubmit the claim to the current payer, as they will not change their stance on coverage.
What to Check
- The remittance advice details for the prior payer's decision on the claim.
- The Claim Adjustment Reason Code associated with the N536 remark for further context.
- Patient account records to verify the patient's responsibility and any prior payment history.