M138Remark Code (RARC)Active
M138 Remark Code - Patient Not Enrolled in Demonstration
The M138 remark code indicates that the patient was identified as a demonstration participant, but they were not enrolled in the demonstration program at the time the services were provided. This means that coverage for the services is limited and not applicable since the patient does not meet the demonstration criteria during that service period.
How It Relates to the Denial
M138 typically accompanies a Claim Adjustment Reason Code that indicates a denial due to non-coverage for services provided to patients not enrolled in a specific demonstration program. The combination signals that the services rendered are not covered because the patient was not an active participant in the demonstration at the time of service.
Common Scenarios
1A patient received a physical therapy service billed under a demonstration program, but the remittance shows a denial with the M138 remark code.
→ In this case, the M138 remark code clarifies that the patient was mistakenly identified as a demonstration participant, and since they were not enrolled when the service was provided, the claim is not eligible for coverage.
2An outpatient procedure was performed for a patient who was believed to be part of a demonstration program, yet received a denial accompanied by remark code M138.
→ The M138 remark code indicates that the patient was not properly enrolled in the demonstration program at the time of the procedure, which explains the denial for coverage.
3A claim was submitted for a routine check-up for a patient, but the payment was denied with the M138 remark code noted on the remittance advice.
→ The M138 remark informs the biller that the patient was not enrolled in the demonstration program when the check-up occurred, leading to the denial of the claim.
What to Do
- Verify the patient's enrollment status in the demonstration program during the service dates.
- Consider resubmitting the claim if the patient was enrolled at the time and provide proof of enrollment if applicable.
- Review the original claim details to ensure accurate billing related to the demonstration program.
What to Check
- The patient's demonstration program enrollment records for the service dates.
- The claim adjustment reason code that accompanies the M138 remark for additional context.
- Documentation that supports the patient's eligibility for the demonstration program during the service period.