Remark code M16 is an alert indicating that the healthcare provider should refer to the payer's website, mailings, or bulletins for additional information regarding the specific policy, procedure, or decision related to the claim.
Common causes of code M16 are:
- Missing/incomplete/invalid information on the claim form that is essential for payer adjudication.
- Failure to provide necessary documentation or information when requested by the payer.
- Errors in patient demographic information such as name, date of birth, or insurance ID number.
- Lack of a required referral or prior authorization for the service or procedure billed.
- Omission of necessary procedure codes or diagnostic codes that justify the medical necessity of services.
- Incorrect use of billing codes or modifiers that do not align with payer guidelines.
- Failure to update or verify patient insurance information before submitting the claim, leading to discrepancies.
- Submission of a claim for services not covered under the patient's current insurance plan or policy.
Ways to mitigate code M16 include staying updated with the latest billing guidelines and payer policy changes by regularly checking the payer's website, subscribing to their newsletters, and attending any relevant training or webinars they offer. Ensure that your billing team is aware of the most current information and understands how to apply it to claims submissions. Implement a process for timely review and dissemination of any new information received through mailings or bulletins to all relevant staff members. Additionally, consider setting up alerts or reminders to check for updates on a routine basis to ensure compliance with the latest policies and procedures.
The steps to address code M16 involve a multi-faceted approach to gather the necessary information and take appropriate action. First, access the payer's website using the provider portal or the specific URL provided in the remark code message. Look for a search function or a dedicated section for updates, mailings, or bulletins related to policies, procedures, or decisions.
Once on the website, enter relevant keywords or the code itself into the search bar to locate the specific document or announcement referenced by the remark code. If the search doesn't yield results, navigate to the sections where policy updates or bulletins are typically posted.
Review the identified documents thoroughly to understand the details of the policy or procedure change that has prompted the remark code. Pay special attention to any new billing guidelines, coverage limitations, or documentation requirements that may affect claim submission or processing.
After reviewing the information, evaluate the affected claims to determine if they comply with the updated policy or procedure. If the claim was denied or adjusted due to non-compliance, make the necessary corrections based on the new information. This may involve adjusting codes, enhancing documentation, or submitting additional information as required by the payer.
If the policy update requires a broader change in practice operations or billing processes, develop an action plan to implement these changes. This may include staff training, updating electronic health record (EHR) templates, or revising internal billing guidelines.
Finally, if the information on the website is unclear or if you have specific questions about how the policy affects your claims, reach out to the payer's provider support or customer service for clarification. Document all communications and any additional guidance provided for future reference.