B7 — Provider Not Certified/Eligible (Enrollment)

Denial Identifier

• Primary CARC: B7 — "This provider was not certified/eligible to be paid for this procedure/service on this date of service." (X12)
• Related CARCs: 170 (payment denied when performed/billed by this type of provider), 171 (in this type of facility), 172 (adjusted when billed by a provider of this specialty), 8 (procedure inconsistent with provider type/specialty/taxonomy), B6 (payment adjusted when performed/billed by this type of provider/facility/specialty)
• Common RARC: N95 — "This provider type/provider specialty may not bill this service."

Plain-Language Meaning

• The payer's enrollment records show this provider was not enrolled, not credentialed with this specific plan, or not eligible to bill this specific service/specialty combination as of the date of service.

Why the Claim Was Denied

• Provider credentialing/enrollment: provider's Medicare/Medicaid/commercial enrollment lapsed, was pending, or never included the billed taxonomy/specialty
• Claim construction: correct provider is enrolled, but the wrong taxonomy code or specialty was submitted on the claim
• Payer processing: enrollment is active but the payer's provider file has not been updated

Information the Biller Must Review

• Billing/rendering provider NPI, taxonomy code submitted, provider's enrollment status and effective dates with the specific payer/plan, payer provider-directory/roster listing, credentialing file.

What Needs to Be Corrected

• Claim correction: If the provider is properly enrolled and only the taxonomy or specialty field was wrong on the claim, correct and resubmit.
• Upstream correction: If the provider genuinely is not enrolled/credentialed with that payer, this is a Credentialing/Provider Enrollment issue — the claim cannot be fixed by changing the provider listed on it.

Resolution Workflow

• Verify the provider's enrollment/credentialing status with the specific payer for the date of service.
• Compare the taxonomy/specialty submitted on the claim to what is on file with the payer.
• If only the claim's taxonomy field was wrong, correct and resubmit.
• If enrollment truly lapsed or was never completed, route to Provider Enrollment/Credentialing to resolve enrollment; do not bill under a different, uninvolved provider.
• Document the enrollment verification outcome.
• Escalate to Credentialing/Contracting leadership for retroactive enrollment or effective- date disputes.

Department Most Likely Responsible

• Resolves current claim: Credentialing/Provider Enrollment, Billing. Prevents recurrence:
• Credentialing/Provider Enrollment — proactive roster reconciliation against payer enrollment status before providers begin seeing patients under a given plan.

Prevention Control

• Provider enrollment roster reconciliation against active payer effective dates; pre-service check that a new provider's enrollment is active before scheduling patients under that plan; periodic re-credentialing tracking.

Escalation Trigger

• Provider is not enrolled and the service already occurred (compliance and revenue-at-risk issue); enrollment effective-date dispute with the payer; recurring enrollment gaps for new hires.

Sample Scenario

• Scenario: Claim denied B7/N95.
• Finding: Provider's enrollment application with this specific payer was still pending on the date of service.
• Action: Claim held pending enrollment approval; retroactive billing pursued per payer policy once enrollment is finalized (payer-specific whether retroactive billing is allowed).

Resolution path at a glance

AI Search Terms / Synonyms

• B7; provider not certified; provider not eligible; not enrolled denial; credentialing denial; N95.

AI Answer Guardrail

• Verify actual enrollment/credentialing status with the specific payer before recommending any claim correction, and never suggest substituting a different provider who did not render the service.

Sources

• X12 CARC list; X12 RARC list