Remark code M115 indicates that the claim item in question has been denied because it was provided to the patient by a supplier who does not have a contract with the payer or is not part of a demonstration project. This means that for the service or item to be covered, it must be obtained from a supplier that has an established agreement with the insurer or is participating in a specific demonstration program that the payer recognizes.
Common causes of code M115 are:
1. The healthcare provider or supplier who rendered services is not part of the payer's contracted network of providers.
2. The patient received services from a supplier who is not participating in a Medicare demonstration project that the patient is enrolled in.
3. The provider or supplier has not agreed to the terms and conditions set forth by the payer for the specific service provided.
4. The claim was submitted for a service that requires the provider to be a contracted or demonstration supplier, but the provider has not fulfilled these requirements.
5. There may have been an administrative error where the provider's contract or demonstration status was not correctly recorded or updated in the payer's system.
6. The patient may have switched to a new insurance plan and received services from a provider who was covered under their previous plan but is not contracted with the new plan.
Ways to mitigate code M115 include ensuring that your practice has a current and active contract with the patient's insurance provider. Regularly verify the status of your agreements and keep an updated list of insurance networks in which your practice participates. Before providing services, always check the patient's insurance plan to confirm that your practice is considered an in-network provider. Additionally, educate your front-office staff to perform eligibility and benefits verification for each patient prior to service delivery. Establish a protocol for referring patients to contracted providers if your practice is not within their network to avoid this denial code.
The steps to address code M115 involve verifying the provider's participation status with the patient's insurance plan. If the provider is indeed non-contract or non-demonstration, consider referring the patient to a contracted supplier within the patient's network. If the provider should be in-network, contact the insurance company to update their records and resubmit the claim. Additionally, review the patient's insurance benefits to ensure that services are covered when provided by in-network suppliers and check for any updates in contract status that may not have been communicated effectively. If the claim was submitted with incorrect provider information, correct the billing information and resubmit the claim.