Denial · CARC 11
CODING · MERIDIAN HEALTH PLAN
Classification
| Field | Value |
|---|---|
| Primary CARC | 11 |
| All CARCs | 11 |
| Root cause | CODING |
| Owns the fix | HIS |
| Appealable | yes |
| Recoverable | yes |
| Recommended action | Diagnosis inconsistent with procedure; review coding and resubmit. |
| Payer | MERIDIAN HEALTH PLAN |
| Denial date | 7 Jul 2024 |
| Appeal deadline | 5 Oct 2024 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
$431.26 paid, $275.74 withheld
Billed $707.00. The payer paid $431.26, withheld $275.74. Of the $275.74 withheld, $275.74 is modelled as recoverable; less $31.00 to work it, that is $244.74 net. Diagnosis inconsistent with procedure; review coding and resubmit. The modelled filing window closed 717 days ago. Confirm the contractual deadline before deciding whether a late submission or reconsideration is still open.
From: 835 CLP amounts and CAS adjustments on this claim; the denial derivation for the modelled recoverable amount and filing window.
Limits: Patient responsibility reported on an 835 is not revenue. This application cannot say whether the practice billed it, whether the patient paid, or whether a secondary payer covered it — those live in a billing system it does not read. The recoverable figure and the deadline are estimates, not a payer commitment.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/11 | 275.74 | withheld |