N856Remark Code (RARC)Active
N856 Remark Code - Coverage Not Under ERISA
The N856 remark code indicates that the coverage in question is not governed by the exclusive jurisdiction of the Employee Retirement Income Security Act (ERISA) of 1974. This suggests that the payer is clarifying the legal framework under which the claim is being processed, potentially affecting coverage decisions or appeals.
How It Relates to the Denial
The N856 remark typically accompanies an adjustment reason code that relates to coverage determinations, particularly when the payer is indicating that ERISA does not apply to the specific claim or coverage. This combination often signals that the claim may be subject to state regulations instead of federal ERISA regulations.
Common Scenarios
1A provider submits a claim for a patient enrolled in a health plan that is not governed by ERISA, such as certain state-sponsored plans. The remittance shows a denial with an adjustment reason code regarding coverage.
→ The N856 remark clarifies that the plan's coverage is not under ERISA, which may mean different state laws apply. The payer expects the provider to understand the jurisdictional implications for this claim.
2A facility bills for outpatient services provided to a patient with a non-ERISA plan. The remittance indicates a partial payment along with a reason code for an adjustment due to coverage issues.
→ The presence of the N856 remark suggests that the payer is highlighting that ERISA does not govern this coverage, which may impact how the services are reimbursed or what appeals options are available.
3A claim for a preventive service is denied with a reason code related to coverage limitations. The remittance includes the N856 remark indicating the coverage's legal status.
→ This remark indicates that the payer is specifying that the coverage is not subject to ERISA, which may imply that different state laws dictate the coverage limitations for the service in question.
What to Do
- Review the accompanying reason code for specifics on the adjustment made.
- Consider the implications of state law on the claim's coverage and payment terms.
- If applicable, prepare to appeal the decision based on state regulations.
What to Check
- The eligibility response to confirm the plan type and its governing laws.
- The claim adjustment reason code for details on the denial or payment adjustment.
- Any applicable state regulations that might affect coverage under this plan.