Denial · CARC 26
ELIGIBILITY · MERIDIAN HEALTH PLAN
Classification
| Field | Value |
|---|---|
| Primary CARC | 26 |
| All CARCs | 26 |
| Root cause | ELIGIBILITY |
| Owns the fix | Access Related |
| Appealable | yes |
| Recoverable | yes |
| Recommended action | Expenses incurred prior to coverage. Check the enrolment span before appealing. |
| Payer | MERIDIAN HEALTH PLAN |
| Denial date | 9 Jun 2024 |
| Appeal deadline | 7 Sep 2024 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
The modelled appeal window passed 745 days ago
The 835 reports CARC 26 on 9 Jun 2024, withholding $21.18 from the provider. The matched 834 shows coverage 24 Mar 2024 to open, which includes the service date of 1 May 2024. Modelled recoverable $21.18, less an estimated rework cost of $31.00, leaves -$9.82 net. The configured appeal window for this payer ends 7 Sep 2024, 745 days ago. Recommended action: Expenses incurred prior to coverage. Check the enrolment span before appealing. Confirm the contractual deadline and any exception, reconsideration or correction route with the payer before closing the case. On these estimates the work costs more than it returns; that is a judgement about this model's figures, not a rule.
From: Denial derivation: root cause, appealability, the recoverable amount net of an estimated rework cost, and a filing deadline derived from the denial date.
Limits: The deadline and the recoverable amount are application estimates. The deadline is the denial date plus a configured per-payer window, not a term read from the payer's contract or an appeal notice, and the recoverable figure is a model rather than a promise of payment. Confirm both against the policy before relying on them.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/26 | 21.18 | withheld |