The payer cannot find this patient as a member.
CO — Contractual obligation — the provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
Fix and resubmit. This is a correction, not an appeal. Appealing burns the deadline.
In the order we see it.
A mistyped member ID, or a name that does not match the payer's record.
The patient gave an old card and has since changed plans.
Re-verify the member ID, name spelling and date of birth against the card, then resubmit.
The documentation, not the argument.
Current eligibility showing the correct member ID and plan.
The common mistake. Do not write this off as non-covered. It is almost always a data problem, and the claim pays once the identifiers match.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound