M87Remark Code (RARC)Active
M87 Remark Code - CFO-CAP Prepayment Review Explanation
The M87 remark code indicates that the claim or service has been subjected to a CFO-CAP prepayment review. This means that the payer is conducting a review of the claim before payment is made, typically to ensure compliance with billing guidelines or to verify the medical necessity of the services provided.
How It Relates to the Denial
The M87 remark code typically accompanies adjustment reason codes that indicate a claim is under review or has been denied due to prepayment scrutiny. The combination signals that the payer is assessing the claim before deciding on payment approval.
Common Scenarios
1A provider submits a claim for a surgical procedure, and the remittance advice returns an adjustment indicating a denial due to prepayment review.
→ In this case, the M87 remark code clarifies that the denial is due to the claim undergoing a CFO-CAP prepayment review, meaning the payer needs to assess the necessity and appropriateness of the procedure before payment can be processed.
2A physical therapy claim is submitted, and the remittance shows that payment is pending due to a prepayment review adjustment reason code.
→ The M87 remark code indicates that the claim is being reviewed as part of the CFO-CAP process, suggesting the payer is evaluating the claim details to determine if the services are covered and medically necessary.
3A claim for diagnostic imaging is filed, and the remittance indicates an adjustment for prepayment review with the M87 code listed.
→ The M87 remark code signifies that the payer is conducting a CFO-CAP prepayment review, which could delay payment while the claim is assessed for compliance and necessity.
What to Do
- Wait for the payer's decision after the prepayment review is complete.
- Ensure all documentation supporting the medical necessity of the services is readily available, should the payer request additional information.
What to Check
- The claim details submitted to ensure they align with payer guidelines.
- Any correspondence from the payer regarding the prepayment review process.
- Documentation of medical necessity for the services rendered, as this may be requested during the review.