X12 Ingest & Denial Analytics

The modelled appeal window passed 829 days ago

The 835 reports CARC 27 on 17 Mar 2024, withholding $559.00 from the provider. The matched 834 shows coverage 19 Feb 2024 to 31 Jul 2024, and the service on 14 Feb 2024 falls outside it — but in the direction the stated CARC does not claim. Modelled recoverable $559.00, less an estimated rework cost of $31.00, leaves $528.00 net. The configured appeal window for this payer ends 15 Jun 2024, 829 days ago. 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. Reconcile the enrolment effective date with the reason the payer gave: check whether the enrolment record is complete, whether a retroactive update exists, whether another plan covered the service, and whether the payer used the right reason code. Confirm the contractual deadline and any exception, reconsideration or correction route with the payer before closing the case.

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.

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