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N580 Remark Code: Based on Insurance Policy Provisions

N580 means the payer based its determination on the provisions of the insurance policy under which the claim was filed. It points you to the policy's terms, such as exclusions, limits, or conditions, as the reason for the payment decision.

Quick facts

Code
N580 (RARC N580)
Status
Active In use since July 15, 2013.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • CO (Contractual Obligation): The policy terms place the adjustment on the provider, for example a policy-based fee limit.
  • PR (Patient Responsibility): The policy terms leave the amount with the patient or insured, such as an exclusion or deductible.
  • OA (Other Adjustment): The policy does not cover the amount and another payer may need to be billed.
Official description
Determination based on the provisions of the insurance policy.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What N580 means

N580 is a pointer rather than a reason. It tells you the payer reached its decision by applying the contract language of the insurance policy, but it does not name the clause. That could be an exclusion, a benefit maximum, a condition of coverage, or a definition, for example what counts as a covered person or covered expense.

You will usually find the specific action in the paired CARC, such as P6 (entitlement to benefits), 204 (not covered under the plan), or 96 (non-covered charge).

Common scenarios

  • An exclusion in the policy applies to the service or the circumstances of the injury.
  • A policy limit has been reached for this type of benefit.
  • A condition of coverage was not met, such as notice, cooperation, or documentation.
  • The patient does not meet the policy’s definition of an insured or eligible person.

What to do

  1. Ask for the specific provision. Call the payer or adjuster and request the policy section in writing.
  2. Compare it to the facts of the claim. Policy provisions often have exceptions.
  3. Enlist the insured if the decision seems wrong; they have standing to challenge their own policy’s interpretation.
  4. Bill secondary coverage if the policy clearly excludes the service.
  5. Appeal or dispute through the payer’s process when you have documentation that the provision does not apply.

See how CARC and RARC codes work together.

Codes that may appear with N580

  • CO-P6 (Based on entitlement to benefits.): The adjustment is based on entitlement to benefits.
  • 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.
  • CO-96 (Non-covered charge(s).): A non-covered charge, with the policy named as the reason.
  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Asks you to consult plan benefit documents for restrictions.
  • N578 (Coverages do not apply to this loss.): No coverage on the P&C policy applies to this loss.
  • N584 (Not covered based on the insured's noncompliance with policy or statutory conditions.): Not covered because the insured did not comply with policy or statutory conditions.

N580 FAQ

Which policy provision applies?

N580 doesn't say. Ask the payer or adjuster for the specific section, or check the explanation of benefits sent to the insured, which may cite it.

Is N580 only for auto claims?

It is common on property and casualty claims, but the wording fits any insurance policy, so other payers can use it.

Can I get a copy of the policy?

Providers often do not have direct access. The patient or insured can request the policy or benefit booklet and share the relevant section.