Denial · CARC 26
ELIGIBILITY · NORTHSTAR MUTUAL
Denied
226.00
Withheld
Recoverable
226.00
Realistically collectable
Net of rework
195.00
less 31.00
Appeal window
closed 585d ago
Closed
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 | NORTHSTAR MUTUAL |
| Denial date | 18 Aug 2024 |
| Appeal deadline | 14 Feb 2025 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
Is the available evidence consistent with the stated reason?
Coverage dates are consistent with the stated reason
The payer asserts a coverage problem under CARC 26, and the matched 834 is consistent with it: the service on 16 Jun 2024 predates the coverage start of 29 Jun 2024.
From: 835 CARC against the matched 834 enrolment span.
Limits: Consistent dates are not a finding that the denial is correct. This application holds no payer adjudication snapshot, plan rules or enrolment change history, so it cannot say whether the service should have been eligible under another provision, nor rule out a retroactive update the payer has since received.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/26 | 226.00 | withheld |