Denial · CARC 197
AUTHORIZATION · NORTHSTAR MUTUAL
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 | NORTHSTAR MUTUAL |
| Denial date | 16 Aug 2026 |
| Appeal deadline | 12 Feb 2027 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
$510.03 paid, $17.97 withheld
Billed $528.00. The payer paid $510.03, withheld $17.97. Of the $17.97 withheld, $17.97 is modelled as recoverable; less $31.00 to work it, that is -$13.03 net. Precertification/authorization absent. Check whether one was obtained before appealing. On these estimates the work costs more than it returns, which is a judgement about this model's figures rather than a rule.
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 | 17.97 | withheld |