N926Remark Code (RARC)Active
N926 Remark Code - Partially Denied Explanation
The N926 remark code indicates that a portion of the claim has been denied because the Medicare Advantage Organization (MAO) determined it had no payment responsibility for certain service lines submitted in the encounter record. However, not all service lines were denied, which suggests that some were accepted for payment.
How It Relates to the Denial
The N926 remark code typically accompanies a Claim Adjustment Reason Code that explains the denial of specific service lines. This combination signals to the biller that while some services are covered, others are not, based on the MAO's assessment at the time of submission.
Common Scenarios
1A provider submits a claim for multiple services rendered to a patient enrolled in a Medicare Advantage plan, including both a diagnostic test and a follow-up visit. The remittance advises that only the follow-up visit was covered.
→ The N926 remark code here clarifies that the diagnostic test was denied because the MAO determined it was not responsible for that service line, while the follow-up visit was approved.
2A claim for a surgical procedure and post-operative care is submitted, but the remittance indicates that the surgical procedure was partially denied.
→ In this scenario, the N926 remark code suggests that the MAO found no payment responsibility for the surgical procedure, but may still cover the post-operative care, as indicated by the accompanying adjustment reason.
3A physical therapy claim includes multiple visits, but the remittance shows that some visits were paid and others were denied.
→ Here, the N926 remark code points out that the MAO decided it had no payment responsibility for certain therapy visits based on its review, while approving others.
What to Do
- Review the specific service lines that received the N926 remark to determine which were denied and which were paid.
- Consider appealing the denied service lines if additional documentation can support their medical necessity or coverage under the plan.
- Verify that the services billed align with the patient's coverage and the MAO's guidelines.
What to Check
- The claim adjustment reason code associated with the N926 remark for further details on the denial.
- The patient’s eligibility and benefits documents to confirm coverage for the denied services.
- The encounter record submitted to ensure all services were accurately coded and documented.