Remark code M37 indicates that the service or procedure is not covered by the insurance plan when the patient is under the age of 35.
Common causes of code M37 are typically related to age-specific policy limitations set by the insurance provider. This remark code is used when a claim includes services or procedures that are not covered by the patient's insurance plan because the patient has not reached a certain age threshold, in this case, age 35. The services may be considered routine or preventive for patients above that age, and thus, not eligible for coverage for younger individuals. Examples might include certain screenings or tests that are recommended for patients starting at age 35. If these services are provided to patients under 35, the insurer may use code M37 to indicate that the claim will not be paid. Providers should verify coverage for age-restricted services prior to administering them to ensure they are in line with the patient's benefits.
Ways to mitigate code M37 include implementing a robust verification process to confirm patient eligibility and benefits before services are rendered. Ensure that your scheduling and registration systems prompt for the patient's age and automatically flag cases where the patient is under the age of 35 for services that are not covered for this age group. Training staff to recognize services that are age-restricted and to communicate effectively with patients about their coverage limitations can also help prevent this code from arising. Additionally, consider using advanced analytics to identify patterns in claims denials related to age so that you can proactively address any systemic issues within your practice.
The steps to address code M37 involve reviewing the patient's age to confirm accuracy. If the patient is indeed under age 35, verify if the service provided is typically not covered for patients under this age threshold. If the service should be covered, check for any possible errors in the patient's date of birth or the service code that was submitted. If an error is found, correct the information and resubmit the claim. If the patient's age and the service are correctly reported, and the service is not covered for their age group, inform the patient of the denial and discuss alternative payment options or services that may be covered. If the service is typically covered for patients under age 35, appeal the claim with supporting documentation justifying medical necessity or any applicable exceptions.