M28Remark Code (RARC)Active
M28 Remark Code - Part B Payment Qualification
The M28 remark code indicates that the service billed does not qualify for payment under Part B of Medicare when Part A coverage has been exhausted or is unavailable. This means that the payer is clarifying that the claim cannot be paid under the conditions specified, typically pointing to a coverage issue rather than a billing error.
How It Relates to the Denial
The M28 remark code usually accompanies a Claim Adjustment Reason Code (CARC) that indicates a denial based on the exhaustion of Part A coverage. Together, they inform the biller that the service was not covered under Part B due to the lack of available Part A benefits.
Common Scenarios
1A hospital outpatient service was billed after the patient had already exhausted their Part A benefits, and the claim was denied with a CARC indicating ‘exhausted benefits’.
→ The M28 remark code reinforces the denial by stating that the service cannot be covered under Part B since Part A coverage is not available.
2A skilled nursing facility claim was submitted after the patient's Part A coverage ended, resulting in a denial from the payer.
→ The M28 remark code clarifies that the service rendered does not qualify for Part B payment because Part A coverage is exhausted.
3A home health service claim was denied after the patient reached the limit on their Part A coverage, and the remittance included a CARC about benefit exhaustion.
→ The presence of the M28 remark code indicates that Part B payment is not applicable due to the unavailability of Part A benefits.
What to Do
- Review the patient's benefit status to confirm the exhaustion of Part A coverage.
- Consider appealing the denial if you believe the service should be covered under Part B due to specific circumstances.
- Verify whether any other coverage options are available for the patient.
What to Check
- The patient's Medicare benefit statement to confirm Part A coverage status.
- The claim details to ensure services billed align with covered benefits under Part B.
- Any previous claims submitted that might indicate a pattern of benefit exhaustion.