CO-243: Services Not Authorized by Network/Primary Care Providers
Obtain PCP authorization and resubmit. Do not bill the patient.
What Does CO-243 Mean?
With CO, the missing PCP authorization is a contractual issue. Obtain the authorization and resubmit. The provider cannot bill the patient for this denial.
CARC 243 indicates that the patient's plan requires the network or primary care provider to authorize the service, and that authorization was not obtained. This differs from CARC 197 (payer authorization absent) — CARC 243 specifically refers to authorization from the patient's PCP or network provider, not from the insurance company itself.
In gatekeeper HMO plans, the primary care provider serves as the coordinator of care and must authorize specialist visits, diagnostic tests, and other services before the plan will cover them. Without the PCP's authorization or referral, the service is denied.
Common Causes
| Cause | Frequency |
|---|---|
| No authorization from primary care provider for specialist services The patient's plan requires PCP authorization for the services and no authorization was obtained before or after the service | Most Common |
| Authorization not obtained from network gatekeeper The patient's managed care plan requires authorization from a network gatekeeper provider and the authorization was not obtained | Common |
| Service not authorized by the payer's utilization management The payer's utilization management department did not approve the service as medically necessary | Common |
| Retrospective authorization denied An attempt to obtain retrospective authorization for services already rendered was denied | Occasional |
How to Resolve
- Obtain PCP authorization Contact the patient's PCP for the required authorization or referral.
- Resubmit with authorization Add the authorization number and resubmit.
- Appeal if already authorized If authorization was in place, submit documentation and appeal.
Appeal if an authorization was obtained but not on file with the payer, or if the service qualifies for retrospective authorization based on medical necessity. Include the authorization number, PCP referral documentation, clinical notes, and medical necessity justification.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-243:
| RARC | Description |
|---|---|
| N130 | Consult plan benefit documents/guidelines for coverage of this service. Review the plan's authorization and referral requirements → |
| N386 | This decision was based on a National Coverage Determination (NCD) or Local Coverage Determination (LCD). Review the applicable coverage guidelines for authorization requirements → |
How to Prevent CO-243
- Verify PCP authorization requirements before scheduling specialist services
- Implement pre-visit verification of referral and authorization status
- Maintain communication channels with referring PCPs for authorization coordination
- Train scheduling staff on plan-specific PCP authorization requirements
General Prevention
- Implement a systematic authorization process that checks requirements before scheduling services
- Verify PCP authorization requirements for each patient's plan before providing services
- Obtain all required authorizations before the date of service
- Maintain communication with network PCPs about authorization requirements
- Track authorization status for all scheduled services
- Train staff on plan-specific authorization requirements
Also Filed As
The same CARC 243 may appear with different Group Codes:
Related Denial Codes
Sources
- https://x12.org/codes/claim-adjustment-reason-codes
- https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
- https://www.aapc.com/resources/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.