Denial · CARC 27
ELIGIBILITY · NORTHSTAR MUTUAL
Denied
135.00
Withheld
Recoverable
135.00
Realistically collectable
Net of rework
104.00
less 31.00
Appeal window
closed 361d ago
Closed
Classification
| Field | Value |
|---|---|
| Primary CARC | 27 |
| All CARCs | 27 |
| Root cause | ELIGIBILITY |
| Owns the fix | Access Related |
| Appealable | yes |
| Recoverable | yes |
| Recommended action | Expenses incurred after coverage terminated. Check the enrolment span: if the member was covered on the service date this is wrongly denied and worth appealing. |
| Payer | NORTHSTAR MUTUAL |
| Denial date | 30 Mar 2025 |
| Appeal deadline | 26 Sep 2025 |
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?
Coverage record conflicts with the stated reason
The payer asserts a coverage problem under CARC 27. The matched 834 shows coverage from 15 Sep 2024 to open, which includes the service date of 21 Feb 2025. The payer would need to re-check the eligibility source it adjudicated against.
From: 835 CARC against the matched 834 enrolment span.
Limits: A coverage span is not a final benefit determination. A retroactive termination, a plan rule or a different eligibility feed on the payer's side could each explain the difference, and none of them is visible here.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/27 | 135.00 | withheld |