'Prior authorization required' denials
The service required pre-approval that wasn't obtained. Appealable when the auth was attempted, when the service was urgent, or when the plan changed PA requirements mid-year.
What this denial means
A prior-authorization-required denial (CARC 197 or 15) means the service required plan approval before it was rendered, and that approval wasn't obtained — or was obtained but didn't cover what was actually done. The plan won't pay. The two patterns: (a) the provider didn't request auth at all, (b) the request was denied but the service was performed anyway because the clinical situation demanded it.
How to appeal it
The strongest retro-PA appeals document: (1) the clinical urgency that prevented obtaining auth in advance (emergency, post-stabilization, intra-operative finding); (2) the call logs or fax records showing auth was attempted; (3) the change in the plan's PA list mid-year if the provider relied on the prior absence of a requirement; (4) when the service is emergency-related, the Prudent Layperson Standard (ACA §2719A) prohibiting denial of emergency services for failure to pre-auth. Many state insurance laws also restrict retroactive PA denial.
Frequently asked questions
What does “prior authorization required” mean?
A prior-authorization-required denial (CARC 197 or 15) means the service required plan approval before it was rendered, and that approval wasn't obtained — or was obtained but didn't cover what was actually done. The plan won't pay. The two patterns: (a) the provider didn't request auth at all, (b) the request was denied but the service was performed anyway because the clinical situation demanded it.
How do I appeal a 'prior authorization required' denials?
The strongest retro-PA appeals document: (1) the clinical urgency that prevented obtaining auth in advance (emergency, post-stabilization, intra-operative finding); (2) the call logs or fax records showing auth was attempted; (3) the change in the plan's PA list mid-year if the provider relied on the prior absence of a requirement; (4) when the service is emergency-related, the Prudent Layperson Standard (ACA §2719A) prohibiting denial of emergency services for failure to pre-auth. Many state insurance laws also restrict retroactive PA denial.
Related
- CARC 15 — The authorization number is missing, invalid, or does not ap…The authorization number is missing, invalid, or does not apply to the billed services or provider.
- CARC 197 — Precertification/authorization/notification/pre-treatment ab…Prior authorization was required but wasn't obtained before the service. The carrier won't pay.
- CARC 198 — Precertification/notification/authorization/pre-treatment ex…Prior auth was obtained but the service exceeded what was approved (more units, longer stay, differe
- CARC 210 — Payment adjusted because pre-certification/authorization not…Payment adjusted because pre-certification/authorization not received in a timely fashion.
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