DenialIntel

Not necessarily — $148.85 reported as patient responsibility

Not necessarily. The payer reported $148.85 as patient responsibility on this 835. The 835 reports $148.85 under group PR on this claim, which the payer adjudicated as a denial. It carries CARC 96 and claim-level RARC N130. CARC 96: Non-covered charge(s). RARC N130: Consult plan benefit documents/guidelines for information about restrictions for this service. The payer declined coverage because it treats the service as excluded from the plan rather than as a judgement about the care given, and assigned the reported amount to patient responsibility. Compare the provider's itemised bill with the explanation of benefits; request the applicable coverage policy; ask the provider whether the clinical record supports reconsideration or appeal; and confirm any deadline and process with the plan. If a balance remains, ask the provider about payment or financial-assistance options. Ask the plan which exclusion applies and whether any exception exists, and confirm whether notice was given before the service.

From: 835 CAS adjustments under group PR on this claim, with the remark codes reported alongside them; the CARC and RARC reference lists for the code descriptions.

Limits: The 835 records the payer's adjudication. This application cannot determine whether the provider billed the amount, whether it is legally collectible, whether required prior notice was given, whether another payer is responsible, or whether an appeal would succeed.

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