Remark code M116 indicates that the claim has been processed as part of a special demonstration project or program. It also serves as a notification that the project or program is concluding, and as a result, any further services rendered may not be eligible for payment under the terms of the now-ending project or program. Providers should be aware of this when planning future services for patients involved in such projects.
Common causes of code M116 are typically related to the conclusion of a specific healthcare demonstration project or program under which certain services were previously covered. These causes may include:
1. The natural expiration of a temporary healthcare initiative or pilot program that was funding specific services or procedures.
2. A decision by the funding entity, such as the government or a private organization, to terminate the program ahead of schedule.
3. The transition of a healthcare provider out of a demonstration project, either due to non-compliance with the program's requirements or a strategic business decision.
4. Changes in legislation or policy that result in the discontinuation of the program or its funding.
5. The successful completion of a demonstration project, which may lead to the integration of certain services into regular coverage but also the cessation of others.
6. The patient receiving services has exhausted the benefits or services allocated under the demonstration project or program.
In any case, when code M116 appears, it indicates that the provider should not expect additional services to be paid under the terms of the now-ending project or program. Providers may need to seek alternative funding sources or adjust their billing practices accordingly.
Ways to mitigate code M116 include staying abreast of the timelines and conditions of demonstration projects or programs in which your healthcare organization participates. Ensure that billing staff are aware of the end dates for these projects and adjust billing practices accordingly. Regularly review updates from payers about demonstration projects and incorporate this information into your revenue cycle management processes. Additionally, establish a system for flagging claims that are associated with these projects to monitor their status and transition smoothly to standard billing methods once the project concludes. It's also beneficial to communicate with the payer to understand what services will be covered post-demonstration and to negotiate terms for services that may no longer be covered under the project.
The steps to address code M116 involve several key actions. First, verify the end date of the demonstration project or program to ensure that the services billed were provided within the coverage period. If services were provided before the end date, review the claim for accuracy and resubmit if necessary. If services were provided after the end date, check for alternative billing options or coverage under standard payer policies. Communicate with the payer to understand any transition plans or follow-up steps required for claims associated with the ending project or program. Additionally, update your billing system and inform relevant staff about the conclusion of the project or program to prevent future claims from being denied for the same reason. Lastly, explore other funding sources or programs that may cover the services previously included in the demonstration project or program, and advise the healthcare provider on how to transition to these new billing practices.