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N130 Remark Code: See Plan Benefit Documents

N130 means the payer is directing you to the plan's benefit documents or guidelines for information about restrictions on this service. It explains the reason code it accompanies, often a non-covered charge or a fee schedule limit, rather than naming the specific restriction itself.

Code: N130 (RARC N130)
Status: Active In use since October 31, 2002; last modified November 1, 2009.
Code set: Remittance Advice Remark Codes (RARC)
Group codes: PR (Patient Responsibility): With a non-covered charge, the plan excludes or limits the service and the member is generally responsible for the amount.
CO (Contractual Obligation): With a fee schedule reduction, the amount above the allowed rate is a contractual write-off the provider cannot bill to the patient.
Official description: Consult plan benefit documents/guidelines for information about restrictions for this service.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified: September 24, 2026 against the official X12 list.

What N130 means

N130 is a pointer. Instead of stating the rule, the payer tells you the restriction lives in the member’s plan documents: the certificate of coverage, summary plan description, or benefit guidelines. The action you take depends on the reason code with it.

PR-96 with N130: the plan does not cover the service, or limits it, and the charge is assigned to the member.
CO-45 with N130: the charge exceeded the allowed amount, and the plan documents are cited for the payment limit.

Common causes

The service is excluded or limited under this particular plan, even though other plans from the same payer cover it.
A visit or dollar limit in the plan was reached.
The service is covered only in certain settings or with certain conditions described in the plan.
The billed amount was above the allowed amount set by the plan’s payment terms.

What to do

Identify the reason code paired with N130 and its group code.
Ask the payer which plan provision applied. Note the name of the representative and a reference number.
For PR-96, confirm the restriction and, if the patient was informed and the contract permits, bill the patient. Otherwise write it off.
For CO-45, adjust the balance to the contracted rate. If the allowed amount looks wrong, compare it with your fee schedule and dispute it with the payer.
Appeal if the plan language does not support the decision.

How to prevent it

Check benefits for services that plans often limit before scheduling them, and tell patients when a service may not be covered. Reviewing which plans produce N130 most often, by service, shows where front-end benefit checks would help; the CARC and RARC analysis guide outlines that approach.

Codes that may appear with N130

CO-96 (Non-covered charge(s).): Non-covered charge; the specific restriction is in the plan documents. Confirm it and bill the patient only if the plan and any notice rules allow.
CO-45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.): Charge exceeds the fee schedule, with the plan documents cited for the limit. Adjust to the contracted rate.
PR-204 (This service/equipment/drug is not covered under the patient's current benefit plan): The service is not covered under the patient's current benefit plan.

N115 (This decision was based on a Local Coverage Determination (LCD).): Points to a Local Coverage Determination instead of plan documents.
N216 (We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package.): The payer does not cover this type of service, or the patient is not enrolled in that part of the benefit package.
PR-119 (Benefit maximum for this time period or occurrence has been reached.): A benefit maximum has been reached, a common plan restriction.

N130 FAQ

How do I find out what the restriction is?

Call the payer's provider line or check its portal for the member's benefit summary. Ask which provision in the plan documents applied to this service and date.

Can I bill the patient when N130 appears?

Only when the reason code is patient responsibility (for example PR-96) and your contract permits it. With CO-45 the reduction is a contractual write-off.

Is N130 appealable?

If the plan documents do not actually restrict the service, or the patient met an exception, yes. Quote the plan language in the appeal.

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