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N919 Remark Code: Out-of-Pocket Maximum Met

N919 means the family or individual member out-of-pocket maximum has been met. Once that limit is reached, the plan generally stops applying deductible, coinsurance, and copays to covered in-network services for the rest of the benefit period.

Quick facts

Code
N919 (RARC N919)
Status
Active In use since March 1, 2026.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • PR (Patient Responsibility): Should be zero or reduced for covered services once the maximum is met. Any remaining PR amount may relate to non-covered services or amounts that do not count toward the maximum.
  • CO (Contractual Obligation): Contractual adjustments continue to apply as usual and are not affected by the out-of-pocket maximum.
Official description
Family/member out-of-pocket maximum has been met.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What N919 means

Health plans cap how much a member, or a family, pays for covered services in a benefit period. Deductibles, coinsurance, and copays all build toward that cap. When the payer’s accumulator shows the cap has been reached, it pays covered services in full at the allowed amount.

N919 explains why a claim that would normally carry patient cost sharing now shows little or none. It is good news for the patient and a signal for your front desk.

What to do

  1. Post the payment and check whether any patient balance remains.
  2. Refund overpayments if the patient paid copays or deposits for this service.
  3. Update the patient’s account so upcoming visits are not charged at the door for cost sharing that no longer applies, until the benefit period resets.
  4. Watch the timing. Claims processed out of order can mean cost sharing hit an earlier or later claim differently than expected. Reprocessing sometimes shifts amounts between claims.

Why it matters

Collecting cost sharing that the plan will not apply creates refunds, extra work, and patient frustration. Checking accumulators in the eligibility response before collecting helps avoid that.

Codes that may appear with N919

  • CO-45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.): The contractual adjustment that still applies after the out-of-pocket maximum is met.
  • N16 (Family/member Out-of-Pocket maximum has been met.): An older remark stating the out-of-pocket maximum was met and payment was based on a higher percentage.
  • N549 (Alert: Patient's calendar year out-of-pocket maximum has been met.): The patient's calendar-year out-of-pocket maximum has been met.
  • PR-1 / PR-2 / PR-3 (Deductible, coinsurance, and co-payment amounts.): The cost-sharing adjustments you would expect to stop appearing once the maximum is met.

N919 FAQ

Does N919 mean the patient owes nothing?

For covered services that count toward the maximum, usually yes for the rest of the benefit period. Non-covered services, out-of-network balances, and some excluded amounts may still be the patient's responsibility.

What is the difference between family and member maximums?

Family plans usually have an individual maximum for each person and a family maximum across everyone. Reaching either can stop cost sharing, depending on plan design.

What if I already collected cost sharing?

Compare collections with the remittance and refund any amount the patient paid that the payer now shows as not owed.