Denial · CARC 26
ELIGIBILITY · NORTHSTAR MUTUAL
Classification
| Field | Value |
|---|---|
| Primary CARC | 26 |
| All CARCs | 26 |
| Root cause | ELIGIBILITY |
| Owns the fix | Access Related |
| Appealable | yes |
| Recoverable | yes |
| Recommended action | Expenses incurred prior to coverage. Check the enrolment span before appealing. |
| Payer | NORTHSTAR MUTUAL |
| Denial date | 22 Dec 2024 |
| Appeal deadline | 20 Jun 2025 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
Service is outside the coverage span, but the stated CARC timing does not match
The matched 834 shows coverage from 20 Jul 2024 to 3 Oct 2024, and the service on 30 Oct 2024 falls outside it — so the matched 834 does not show active coverage on the service date. But CARC 26 asserts the service came before coverage began, which is not what the record shows. The effective date and the adjudication reason should be reconciled before deciding what to do.
From: 835 CARC against the matched 834 enrolment span, and the direction each asserts.
Limits: A mismatched reason code is not proof the denial is wrong: the claim is still outside the recorded span. It does mean the payer's stated justification cannot be verified as given, and a retroactive enrolment change could explain either the dates or the code.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/26 | 763.00 | withheld |