CARC 31
Patient not found as a member
The payer cannot match the patient to anyone on its records — often a data problem rather than a coverage problem.
Why you actually get this
- A transposed digit in the member identifier.
- A name mismatch — a married name on the claim against a maiden name on file, or a nickname.
- A date of birth keyed incorrectly at registration.
- The claim went to the wrong payer or the wrong plan within a payer.
How to check whether it’s correct
- 01Compare the member ID on the claim against the card, character by character.
- 02Check the name and date of birth exactly as the payer holds them, not as the patient gave them.
- 03Confirm the payer identifier routed the claim where it was meant to go.
Usually worth appealing
Most of these are correctable data errors rather than genuine coverage failures, and a corrected claim pays. Treating this as uncollectible is a common and expensive mistake.
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.