N826Remark Code (RARC)Active
N826 Remark Code - Medicare Shared Savings Program Eligibility
The N826 remark code indicates that the patient did not qualify for the Medicare Shared Savings Program based on the established inclusion criteria. This remark supplements the primary claim adjustment reason code, providing additional context for the denial or adjustment related to the patient's eligibility in the program.
How It Relates to the Denial
The N826 code typically accompanies adjustment reason codes that pertain to eligibility issues or program compliance. The combination signals that the claim was denied or adjusted due to the patient's failure to meet specific program criteria, often related to Medicare's shared savings initiatives.
Common Scenarios
1A provider submitted a claim for a patient's service under the Medicare Shared Savings Program, but the remittance shows an adjustment indicating ineligibility.
→ The N826 remark clarifies that the patient's services were not covered because they did not satisfy the requirements for inclusion in the Medicare Shared Savings Program.
2A hospital billed for a procedure performed on a patient enrolled in a Medicare plan, but received a denial stating that the patient is not eligible for the shared savings program.
→ The presence of the N826 remark suggests that the payer has determined the patient did not meet the necessary criteria for participation in the Medicare Shared Savings Program, leading to the denial.
3A claim for a preventive service was submitted for a Medicare patient, but the remittance indicates an adjustment with a reason code and includes the N826 remark.
→ The N826 remark indicates that despite the preventive service being appropriate, the patient did not meet the inclusion criteria for the shared savings program, affecting the claim's payment.
What to Do
- Review the patient's eligibility for the Medicare Shared Savings Program and any applicable criteria.
- Consider appealing the adjustment if you believe the patient meets the inclusion criteria based on documentation.
- Ensure all documentation supporting the patient's eligibility is accurate and readily available.
What to Check
- The patient's enrollment status in the Medicare Shared Savings Program.
- The specific inclusion criteria for the Medicare Shared Savings Program as outlined by the payer.
- The claim adjustment reason code accompanying the N826 remark for further context.