X12 Ingest & Denial Analytics

What the enrolment record says about the payer's assertion.

Of the eligibility denials this check could settle, 51.0% by value were refused against members our own enrolment shows as covered on the date of service — review or appeal candidates. A reason/date mismatch is counted separately: the service falls outside the recorded span, but in the direction the stated CARC does not claim, so the payer's own justification cannot be verified as given.

Review or appeal candidates

Reason and dates disagree

The service falls outside the recorded coverage span, so the matched 834 does not show active coverage on the service date. But the CARC asserts the other direction — 26 claims the service came before coverage began, 27 that it followed a termination — so the payer's stated reason does not describe its own record. Reconcile the effective date and the adjudication reason before deciding the next action.