AGAR Guide

Eligibility & Coverage

AR Guide Knowledge

Coverage verification failures, member not found, coverage lapsed or terminated, and eligibility requirements not met.

Denial Decoder

Run this denial through the decoder

Enter the codes from your ERA/EOB and get this workflow with the exact CARC/RARC on your line.

Open Denial Decoder

Check first

Check these before anything else

  • Date of service (not today's date)
  • Member ID, name and DOB exactly as submitted
  • Coverage effective and termination dates
  • Eligibility verification response for the DOS
  • Claim history for previously paid services on the same coverage
  • Group code + CARC from the ERA/EOB

Verify payer-specific rules: Heads up

Eligibility responses and coverage rules are payer- and plan-specific. Verify the exact date of service with the payer's own eligibility tools before appealing — a stale or incorrect verification can cause a second denial.

AR Guide knowledge

What it means

The payer could not confirm the patient was covered under the plan for the date of service, or the service is subject to an eligibility requirement the member did not meet. This can be a data mismatch (wrong member ID, name, or DOB) or a genuine coverage gap.

AR Guide knowledge

Common causes

  • Member ID, name, or date of birth mismatch on the claim
  • Coverage lapsed or terminated before the date of service
  • Eligibility not verified before the service was rendered
  • Service date outside the coverage period
  • Eligibility requirement (residency, enrollment) not met

AR Guide knowledge

What AR should verify

  • Re-verify eligibility for the exact date of service with corrected member data
  • Confirm the member ID and subscriber information against the member card
  • Check the coverage effective and termination dates on file
  • Review claim history for a previously paid service on the same coverage
  • Confirm whether coverage was reinstated retroactively

Recommended workflow

What to do next

  1. If the data was wrong, correct the member information and resubmit
  2. If coverage existed but verification failed, appeal with the eligibility confirmation
  3. If the patient was genuinely not covered, bill per applicable patient-responsibility rules
  4. Implement front-end eligibility verification to prevent future denials

Don’t assume

Avoid these shortcuts

  • Today's eligibility proves coverage on the date of service
  • The member ID on the card matches the payer's records
  • A 'member not found' response means the patient has no coverage
  • Coverage status cannot change retroactively
  • The denial is about the service — it may be about the member data

AR Guide knowledge

Documentation

  • Eligibility verification response for the date of service
  • Member ID card copy and subscriber information
  • Coverage reinstatement or retroactive eligibility documentation
  • Claim history showing prior coverage for the same member

AR Guide knowledge

Escalation

  • Eligibility: when verification responses are inconsistent or incomplete
  • Client: when the patient's coverage information was not provided accurately
  • Appeals: when coverage existed but the denial is based on stale data

QA checkpoint

Confirm before closing

  • Verify eligibility before rendering service, not after the denial
  • Store the verification reference number with the account
  • Re-check eligibility when there is any gap between scheduling and service date

AR Guide knowledge

Related guides

AuthorizationNon-Covered ServicesPatient Responsibility

Reference

Related codes

Source & review

References

AR Guide editorial research · Last reviewed Aug 15, 2026 · Reviewed. General practice guidance — not official payer or standards documentation. Payer-specific requirements must be verified with the payer.

About this guidance: Note

AR Guide knowledge is general reference content written by our team — it is not payer-specific policy and never replaces the payer’s documentation or your contract. Always confirm specifics with the payer.