Denial · CARC 27
ELIGIBILITY · NORTHSTAR MUTUAL
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 | 12 May 2024 |
| Appeal deadline | 8 Nov 2024 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
Service is outside the coverage span, but the stated CARC timing does not match
The matched 834 shows coverage from 18 Apr 2024 to 30 Aug 2024, and the service on 22 Mar 2024 falls outside it — so the matched 834 does not show active coverage on the service date. But CARC 27 asserts coverage had already terminated, which is not what the record shows. The effective date and the adjudication reason should be reconciled before deciding what to do.
From: 835 CARC against the matched 834 enrolment span, and the direction each asserts.
Limits: A mismatched reason code is not proof the denial is wrong: the claim is still outside the recorded span. It does mean the payer's stated justification cannot be verified as given, and a retroactive enrolment change could explain either the dates or the code.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/27 | 318.00 | withheld |