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N549 Remark Code: Out-of-Pocket Maximum Met

N549 is an alert that the patient's calendar year out-of-pocket maximum has been met. For the rest of that calendar year, the patient generally owes no further deductible, coinsurance, or co-payments for covered services, subject to the plan's terms.

Quick facts

Code
N549 (RARC N549)
Status
Active In use since March 6, 2012.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • PR (Patient Responsibility): Any cost-sharing shown on this claim may be what brought the patient to the maximum. After that, covered services generally carry no patient cost-sharing.
Official description
Alert: Patient's calendar year out-of-pocket maximum has been met.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What N549 means

The out-of-pocket maximum is the ceiling on what a patient pays in cost-sharing for covered services in a year. N549 says this patient has reached it for the calendar year. From here on, the plan generally pays covered services in full, according to its terms.

Like N548, the alert calls for no claim correction. Its value is in managing patient balances.

What to do

  1. Post this claim as processed, including any remaining patient cost-sharing shown on it.
  2. Flag the account so staff stop collecting co-pays or coinsurance for covered services for the rest of the calendar year.
  3. Review recent collections. If patients paid at the visit after the maximum was reached, refund credits per your policy.
  4. Keep exceptions in mind. Non-covered services and some out-of-network amounts may still be billable.

Updating the patient’s benefits as soon as this alert arrives avoids overcollection and the refund work that follows.

Codes that may appear with N549

  • PR-2 (Coinsurance Amount): Coinsurance that may appear on the claim that reached the maximum.
  • PR-3 (Co-payment Amount): A co-payment on the claim that completed the out-of-pocket limit.
  • N548 (Alert: Patient's calendar year deductible has been met.): The patient's calendar year deductible has been met, an earlier milestone.
  • N919 (Family/member out-of-pocket maximum has been met.): The family or member out-of-pocket maximum has been met.
  • N16 (Family/member Out-of-Pocket maximum has been met.): Out-of-pocket maximum met, with payment based on a higher percentage.

N549 FAQ

Does N549 mean the plan pays everything?

For covered services, usually yes for the rest of the calendar year, depending on the plan. Non-covered services, some out-of-network charges, and amounts above the allowed amount may still be the patient's responsibility.

Can I still collect co-pays at the visit?

Once the out-of-pocket maximum is met for covered services, collecting co-pays at check-in can create credits. Verify the patient's status before collecting.

What if claims process out of order?

Payers apply cost-sharing in the order claims are processed, so a later-dated claim can use up the remaining maximum. Watch for adjustments on earlier claims.