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N878 Remark Code: Balance-Billing Consent Not Valid

N878 is an alert that you indicated the patient received notice and consented to balance billing, but the plan found the notice and consent did not meet federal requirements. Payment and cost sharing were calculated under No Surprises Act rules, and balance billing is prohibited.

Code: N878 (RARC N878)
Status: Active In use since March 1, 2022.
Code set: Remittance Advice Remark Codes (RARC)
Group codes: CO (Contractual Obligation): The amount above the plan's No Surprises Act payment and the patient's share. Because the consent was not valid, it cannot be billed to the patient.
PR (Patient Responsibility): In-network-level cost sharing, the only amount the patient owes.
Official description: Alert: The provider or facility specified that notice was provided and consent to balance bill obtained, but notice and consent was not provided and obtained in a manner consistent with applicable Federal law. Thus, cost sharing and the total amount paid have been calculated based on the requirements under the No Surprises Act, and balance billing is prohibited.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified: September 24, 2026 against the official X12 list.

What N878 means

The No Surprises Act lets some nonparticipating providers balance bill for non-emergency services, but only if the patient waives their protections through a formal notice and consent process. The rules on that process are strict: a standard federal form, specific timing before the service, a good faith estimate, and the patient’s signature.

Your claim told the plan that consent was obtained. N878 means the plan reviewed it and decided the notice or consent did not meet those requirements. So the plan processed the claim as a protected out-of-network service, limited the patient to in-network cost sharing, and barred balance billing.

Common causes

The consent was given less than the required time before a scheduled service.
A practice-created form was used instead of the standard notice.
The notice lacked a good faith estimate or other required content.
The patient’s signature or date is missing.

What to do

Pull the signed notice and consent from the patient’s record.
If it met every requirement, contact the plan and ask for reconsideration with the document attached.
If it did not, accept the processing, refund any excess patient payment, and consider open negotiation on the plan’s payment amount.

How to prevent it

Build the notice and consent step into scheduling, using the current CMS standard form and a checklist that confirms timing, estimate, and signature before the visit.

Codes that may appear with N878

CO-45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.): The reduction to the No Surprises Act out-of-network amount.
PR-1 / PR-2 (Deductible and coinsurance amounts.): Cost sharing recalculated at the in-network level.

N879 (Alert: The notice and consent to balance bill, and to be charged out-of-network cost sharing, that was obtained from the patient with regard to the…): Different problem: consent is not permitted for these services at all, however well it was obtained.
N882 (Alert: The out-of-network payment and cost sharing amounts were based on the plan's allowance because the provider or facility obtained the…): The consent was accepted, so the plan's regular out-of-network allowance applied.
N865 (Alert: This claim is subject to the No Surprises Act provisions that apply to nonemergency services furnished by nonparticipating providers during a…): Identifies non-emergency services by nonparticipating providers at participating facilities.

N878 FAQ

What makes notice and consent invalid?

Common problems include not using the required standard notice, giving it too close to the service date, missing signatures, not offering a good faith estimate, or not listing participating alternatives where required.

Can I resubmit with a corrected consent form?

A consent obtained late or on the wrong form usually cannot be fixed after the service. If you have a valid, timely signed form that was not considered, contact the plan and supply it.

What happens to money the patient already paid?

Any amount collected above the PR amount should be refunded to the patient.

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