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N869 Remark Code: Cost Sharing Based on the QPA

N869 is an informational alert. It means the payer calculated the patient's deductible, coinsurance, or copay using the qualifying payment amount (QPA), as the No Surprises Act requires when no state law or All-Payer Model Agreement sets the amount.

Quick facts

Code
N869 (RARC N869)
Status
Active In use since March 1, 2022.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • PR (Patient Responsibility): The patient's share, calculated from the QPA. This is the most the patient owes for the protected service under the No Surprises Act.
  • CO (Contractual Obligation): The difference between your charge and the amount the plan recognized. Balance billing the patient for it is prohibited for services the No Surprises Act protects.
Official description
Alert: Cost sharing was calculated based on the qualifying payment amount, in accordance with the No Surprises Act.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What N869 means

The No Surprises Act protects patients from surprise out-of-network bills for emergency care, certain non-emergency care at in-network facilities, and air ambulance services. For those services, the patient pays in-network-level cost sharing calculated on a “recognized amount.”

When neither a state law nor an All-Payer Model Agreement sets that amount, federal rules default to the lesser of your billed charge or the qualifying payment amount (QPA). N869 tells you the QPA was the figure the payer used for the deductible, coinsurance, or copay on this claim.

N869 explains the patient’s share. It says nothing about whether the plan’s payment to you was fair.

What to do

  1. Post the PR amount as the patient balance. For protected services, that is the ceiling on what the patient owes.
  2. Do not balance bill for the CO difference. Refund any overpayment the patient already made.
  3. Look at the payment separately. If the plan’s payment looks low for an out-of-network service, the No Surprises Act gives you a path to dispute it through open negotiation with the plan. Federal rules set short windows for starting that process, so check them promptly.
  4. Ask the plan for its QPA if you are considering a dispute. Plans are expected to disclose the QPA with the initial payment or notice of denial.

Codes that may appear with N869

  • PR-1 / PR-2 / PR-3 (Deductible, coinsurance, and co-payment amounts.): These carry the dollar amount of the QPA-based cost sharing that N869 explains.
  • CO-45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.): Reports the reduction from your billed charge to the out-of-network amount the plan paid.
  • N870 (Alert: In accordance with the No Surprises Act, cost sharing was based on the billed amount because the billed amount was lower than the qualifying…): Cost sharing used your billed charge instead, because it was lower than the QPA.
  • N867 (Alert: Cost sharing was calculated based on a specified state law, in accordance with the No Surprises Act.): Cost sharing was based on a specified state law rather than the QPA.
  • N868 (Alert: Cost sharing was calculated based on an All-Payer Model Agreement, in accordance with the No Surprises Act.): Cost sharing was based on an All-Payer Model Agreement.
  • N860 (Alert: The Federal No Surprise Billing Act Qualified Payment Amount (QPA) was used to calculate the member cost share(s).): An older alert that also says the QPA was used for member cost share.

N869 FAQ

What is the qualifying payment amount?

It is a benchmark the plan calculates under federal rules, generally based on its median contracted rate for the same or similar service in the same geographic area. It is used for patient cost sharing when no state law or All-Payer Model Agreement applies.

Does N869 mean my payment is final?

Not necessarily. N869 is about the patient's share. The payment to you may be an initial payment that you can dispute through open negotiation and, if needed, federal independent dispute resolution.

Can I collect more than the PR amount from the patient?

Not for services protected by the No Surprises Act. The patient owes only the cost sharing shown; any amount you collected above it should be refunded.