Denial · CARC 197
AUTHORIZATION · NORTHSTAR MUTUAL
Denied
86.49
Withheld
Recoverable
86.49
Realistically collectable
Net of rework
55.49
less 31.00
Appeal window
closed 501d ago
Closed
Classification
| Field | Value |
|---|---|
| Primary CARC | 197 |
| All CARCs | 197 |
| Root cause | AUTHORIZATION |
| Owns the fix | Access Related |
| Appealable | yes |
| Recoverable | yes |
| Recommended action | Precertification/authorization absent. Check whether one was obtained before appealing. |
| Payer | NORTHSTAR MUTUAL |
| Denial date | 10 Nov 2024 |
| Appeal deadline | 9 May 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?
An approved authorisation exists for this member
The payer asserts that authorisation was absent. A 278 response for this member shows 2 approved authorisation(s) on file. The payer would need to check whether one of them covers this exact service and date.
From: 835 CARC 197 against 278 authorisation responses for this member.
Limits: A member-level authorisation is not a service-level match. Approval for one procedure, provider or date range does not establish approval for this claim, and the payer's own decision record is not visible here.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/197 | 86.49 | withheld |