This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident.
Code type
RARC (Remark)
Category
Medical Necessity
Common CARC pairings
RARC N409 appears with a Claim Adjustment Reason Code (CARC) on the 835 electronic remittance advice and gives more detail about the adjustment. These are the CARCs most often paired with RARC N409.
| CARC | Meaning |
|---|---|
| 40 | Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. |
| 96 | Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. |
| P21 | Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. |
See the full resolution workflow for RARC N409
Members of the EDI-Code Intelligence Lab get the step-by-step rework path, appeal language, root-cause drivers, and prevention checklist for every RARC and CARC pairing, plus payer-specific requirements.
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