Denial · CARC 26
ELIGIBILITY · NORTHSTAR MUTUAL
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 Jan 2026 |
| Appeal deadline | 17 Jul 2026 |
Denial workflow
| Field | Value |
|---|---|
| Current status | new |
| Appeal outcome | not recorded |
| Closure reason | not applicable |
What this denial means, and to whom
$241.27 paid, $76.73 withheld
Billed $318.00. The payer paid $241.27, withheld $76.73. Of the $76.73 withheld, $76.73 is modelled as recoverable; less $31.00 to work it, that is $45.73 net. Expenses incurred prior to coverage. Check the enrolment span before appealing. The modelled filing window closed 67 days ago. Confirm the contractual deadline before deciding whether a late submission or reconsideration is still open.
From: 835 CLP amounts and CAS adjustments on this claim; the denial derivation for the modelled recoverable amount and filing window.
Limits: Patient responsibility reported on an 835 is not revenue. This application cannot say whether the practice billed it, whether the patient paid, or whether a secondary payer covered it — those live in a billing system it does not read. The recoverable figure and the deadline are estimates, not a payer commitment.
Adjustments
| Level | Code | Amount | Counts as |
|---|---|---|---|
| line | PI/26 | 76.73 | withheld |