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N426 Remark Code: Not Covered When Self-Administered

N426 means there is no coverage for this item when it is self-administered. It typically applies to drugs billed under a medical benefit that the payer considers usually self-administered by the patient, which that benefit does not cover.

Quick facts

Code
N426 (RARC N426)
Status
Active In use since August 1, 2007.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • PR (Patient Responsibility): The medical benefit excludes the self-administered drug, so the charge may be the patient's responsibility unless another benefit, such as pharmacy coverage, pays.
  • CO (Contractual Obligation): Where the payer treats the denial as contractual, the provider writes off the amount rather than billing the patient.
Official description
No coverage when self-administered.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What N426 means

Medical benefits generally pay for drugs that a clinician administers, while drugs patients take or inject themselves are normally covered under pharmacy benefits. N426 tells you the payer considers the billed drug to be self-administered, so it is not covered under the benefit you billed. Medicare, for example, maintains self-administered drug exclusion lists through its contractors, and commercial plans have comparable policies.

Expect N426 with CARC 96 or CARC 204. Some payers also add a code directing the claim to the pharmacy plan.

Common causes

  • A drug usually self-injected at home was administered in the office and billed with a HCPCS drug code under the medical benefit.
  • The payer’s self-administered drug list was updated and now includes the product.
  • The drug was dispensed for the patient to take home and billed on the medical claim.
  • The administration method on the claim did not reflect a circumstance that the payer’s policy treats differently.

How to fix it

  1. Check the payer’s self-administered drug policy for the specific drug and route of administration.
  2. If the policy excludes it, redirect the drug to the patient’s pharmacy benefit. The pharmacy may dispense it for the patient to bring in or use at home.
  3. Keep the administration service separate. Some payers may still consider an injection or administration service even when the drug is excluded; others will not. Follow their policy.
  4. If the payer misclassified the drug, appeal with its own policy language and the product’s labeling.
  5. For patient liability, follow your contract and any advance notice rules before collecting.

How to prevent it

Before ordering or stocking a drug for in-office use, check whether each major payer covers it under the medical benefit. Flag products on self-administered drug lists in your charge master so staff route them to pharmacy coverage from the start.

Codes that may appear with N426

  • CO-96 (Non-covered charge(s).): Non-covered charge; N426 explains that the drug is not covered when self-administered.
  • PR-204 (This service/equipment/drug is not covered under the patient's current benefit plan): The drug is not covered under the patient's current benefit as billed.
  • CO-280 (Claim received by the medical plan, but benefits not available under this plan.): Benefits are not available under the medical plan and the claim should go to the pharmacy plan.
  • N425 (Statutorily excluded service(s).): A statutory exclusion for the service in general, rather than a restriction tied to how a drug is given.
  • CO-292 (Claim received by the medical plan, but benefits not available under this plan.): The medical plan forwarded the claim to the patient's pharmacy plan.
  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Points you to the plan documents for restrictions on the service.

N426 FAQ

The patient received the drug in our office. Why is it considered self-administered?

Some payers classify drugs by how they are usually given, not how they were given on a specific day. If the drug is usually self-administered, it can be excluded even when your staff administered it.

Where should the drug be billed instead?

Often under the patient's pharmacy benefit, dispensed by a pharmacy. Check the patient's pharmacy coverage and the payer's policy for that drug.

Are there exceptions?

Payers may cover certain drugs under the medical benefit in specific circumstances. Review the payer's self-administered drug policy for the specific product.