Look up another code

N35 Remark Code: Program Integrity or UR Decision

N35 means the payment decision came from a program integrity or utilization review process. A unit that monitors appropriate use, billing accuracy, or potential fraud, waste, and abuse reviewed the claim and made the determination.

Code: N35 (RARC N35)
Status: Active In use since January 1, 2000.
Code set: Remittance Advice Remark Codes (RARC)
Group codes: CO (Contractual Obligation): The denial or reduction is the provider's responsibility and generally cannot be passed to the patient.
PI (Payer Initiated Reduction): A payer-initiated adjustment, typical when a government program's integrity unit makes the decision.
Official description: Program integrity/utilization review decision.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified: September 24, 2026 against the official X12 list.

What N35 means

Payers have units whose job is to make sure services are billed accurately and used appropriately. Government programs call this program integrity, and many plans run utilization review for the same purpose. N35 says the decision on this claim came from one of those processes rather than from automated adjudication or routine claim edits.

Because the remark only describes who decided, the paired CARC carries the actual finding. CARC 216, CARC 50, and CARC 151 are typical.

Common causes

Billing patterns for a service fell outside norms for your specialty and triggered review.
The claim was part of a targeted review of a service type the payer considers high-risk.
Records submitted in response to a request did not support the service, frequency, or level billed.
A prior audit placed the provider on prepayment review.

What to do

Read the determination letter or request one. It usually states the review type and the reason for the decision.
Assemble the complete record, including orders, notes, test results, and signatures.
Respond on time. Integrity reviews often have strict response windows, and missing them can lead to automatic denials.
Appeal with a focused response that addresses each finding.
Check for patterns. If several claims were affected, conduct an internal review of documentation and coding for that service.

How to prevent it

Regular internal audits of high-volume or high-value services help ensure documentation supports what is billed. Respond promptly and completely to records requests, and keep a log of reviews and outcomes by payer and service. Our CARC and RARC analysis guide explains how to spot these trends.

Codes that may appear with N35

CO-216 (Based on the findings of a review organization or the payer's findings.): Based on the findings of a review organization or the payer's own findings.
CO-50 (These are non-covered services because this is not deemed a 'medical necessity' by the payer.): The reviewer found the service not medically necessary.
CO-151 (Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.): The reviewer found the number or frequency of services not supported.

N10 (Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review.): An adjustment based on medical, dental, or peer review, not specifically a program integrity unit.
N109 (Alert: This claim/service was chosen for complex review.): Alert that the claim was selected for complex review.
N199 (Additional payment/recoupment approved based on payer-initiated review/audit.): Additional payment or recoupment approved after a payer-initiated review or audit.

N35 FAQ

Does N35 mean I am suspected of fraud?

Not necessarily. Utilization review and program integrity teams look at many claims for accuracy and appropriate use. Still, repeated N35 decisions are a signal to review your billing and documentation.

Can I appeal an N35 decision?

Usually yes, through the payer's standard appeal process, unless the remittance says otherwise. Include complete records and address the reviewer's specific findings.

Should I talk to counsel?

If N35 is part of a broader audit, records request, or payment suspension, many practices involve a compliance professional or healthcare attorney before responding.

Important: read before using this information

This page is general educational information about a standard industry code set. It is not medical billing, coding, legal, reimbursement, or compliance advice, and it does not create a professional or advisory relationship with ClaimsRevenue.

Code definitions, payer usage, contracts, and laws change, and payers may apply the same code differently. The information is provided “as is,” without warranties of any kind, express or implied, including accuracy, completeness, or currency. You are solely responsible for verifying it against the current official X12 code lists, CMS guidance, your payer contracts, and payer policies before relying on it, and for every billing, coding, collection, and appeal decision you make.

Using this information does not guarantee that any claim will be paid or that any appeal will succeed. To the fullest extent permitted by law, ClaimsRevenue and MOODRX LLC are not liable for any loss or damage arising from its use. Official code descriptions are published by X12 and are quoted for reference only. See our full Claims Validation Disclaimer.