M97Remark Code (RARC)Active
M97 Remark Code - Not Paid to Practitioner Explanation
The M97 remark code indicates that a service was not paid to the practitioner because it was provided to the patient in a specific place of service. The payment for that service is included in the reimbursement issued to the facility where the service was rendered.
How It Relates to the Denial
The M97 remark code typically accompanies a claim adjustment reason code that relates to services billed by a practitioner but where reimbursement is directed to the facility. This combination signals that the payment structure for the service is based on facility reimbursement rather than individual practitioner billing.
Common Scenarios
1A practitioner bills for a consultation provided to a patient in an outpatient hospital setting. The remittance shows a denial for the practitioner’s claim.
→ The M97 remark code clarifies that the consultation was not separately reimbursed to the practitioner because the payment has been included in the facility's overall reimbursement.
2A physician submits a claim for a procedure performed in a facility, but the remittance advises that the claim has been denied with M97.
→ The M97 remark indicates that the payment for the procedure is not directed to the physician but rather is bundled within the facility's payment.
3A nurse practitioner files a claim for services provided during a patient's stay in a hospital. The remittance response includes the M97 code.
→ In this case, the M97 remark explains that the nurse practitioner's services are not paid separately because the facility's reimbursement covers these services.
What to Do
- Verify if the service was indeed provided in a facility setting as indicated by the M97 remark.
- Do not resubmit the claim for separate payment to the practitioner; the payment is included in the facility's reimbursement.
What to Check
- Review the place of service listed on the claim to confirm it matches the facility setting.
- Check the original claim submission for any bundled services that may have been included in the facility's payment.
- Look at the facility's remittance advice for details on the reimbursement that includes the billed service.