Denial · CARC 197
AUTHORIZATION · MERIDIAN HEALTH PLAN
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 | 30 Jun 2024 |
| Appeal deadline | 28 Sep 2024 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
$460.43 paid, $216.57 withheld
Billed $677.00. The payer paid $460.43, withheld $216.57. Of the $216.57 withheld, $216.57 is modelled as recoverable; less $31.00 to work it, that is $185.57 net. Precertification/authorization absent. Check whether one was obtained before appealing. The modelled filing window closed 724 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/197 | 216.57 | withheld |