Denial · CARC 50
MEDICAL_NECESSITY · MERIDIAN HEALTH PLAN
Classification
| Field | Value |
|---|---|
| Primary CARC | 50 |
| All CARCs | 50,45 |
| Root cause | MEDICAL_NECESSITY |
| Owns the fix | Utilization |
| Appealable | yes |
| Recoverable | yes |
| Recommended action | Not deemed medically necessary. Appeal with clinical documentation. |
| Payer | MERIDIAN HEALTH PLAN |
| Denial date | 26 May 2024 |
| Appeal deadline | 24 Aug 2024 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
Nothing withheld — $356.85 now rests with the patient
Billed $549.00. The payer paid $0.00, wrote off $192.15 under the contract, and assigned $356.85 to the patient. The $192.15 contractual write-off is not collectable from anyone — it is the discount the practice agreed with this payer. Nothing is modelled as recoverable from the payer: it withheld nothing on this claim. Not deemed medically necessary. Appeal with clinical documentation. Before billing the patient, confirm the balance against the remittance, check whether notice was given before the service, and check whether a secondary payer applies.
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 | PR/50 | 356.85 | write-off |
| line | CO/45 | 192.15 | write-off |