CARC 26
Service predates the patient's coverage
The date of service falls before the patient's coverage began with this payer.
Why you actually get this
- Coverage started later than the practice believed at registration.
- The patient changed plans and the new card was presented before its effective date.
- A retroactive enrolment has not yet been processed by the payer.
How to check whether it’s correct
- 01Confirm the plan's effective date against the date of service, not the date of billing.
- 02Ask whether a retroactive enrolment is pending — these resolve themselves but only after the fact.
- 03Check whether the patient held different coverage on that date.
Sometimes worth appealing
If a retroactive enrolment is pending, hold and resubmit rather than appeal. If the patient had other coverage on the date of service, bill that payer instead. If neither, this is patient responsibility.
Often arrives with
Seeing a lot of these?
A single denial is a claim to work. A pattern of the same denial is a process to fix, and the two need completely different responses. A free panel reads ninety days of your claims data and shows which codes actually recur for you.
Claim Adjustment Reason Codes are maintained by X12 as External Code List 139. The official description of this code is theirs and is not reproduced here. Check the authoritative list for current wording and status.