Denial · CARC 197
AUTHORIZATION · MERIDIAN HEALTH PLAN
Denied
111.43
Withheld
Recoverable
111.43
Realistically collectable
Net of rework
80.43
less 31.00
Appeal window
closed 731d ago
Closed
Classification
| Field | Value |
|---|---|
| Primary CARC | 197 |
| All CARCs | 197 |
| Root cause | AUTHORIZATION |
| Owns the fix | Access Related |
| Appealable | yes |
| Recoverable | yes |
| Recommended action | Precertification/authorization absent. Check whether one was obtained before appealing. |
| Payer | MERIDIAN HEALTH PLAN |
| Denial date | 23 Jun 2024 |
| Appeal deadline | 21 Sep 2024 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
Is the available evidence consistent with the stated reason?
A request exists, but no approval
The payer asserts that authorisation was absent. A 278 exists for this member but carries no approval, so the record does not contradict the denial.
From: 835 CARC 197 against 278 authorisation responses for this member.
Limits: A member-level authorisation is not a service-level match. Approval for one procedure, provider or date range does not establish approval for this claim, and the payer's own decision record is not visible here.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/197 | 111.43 | withheld |