OA-198: Precertification/Authorization Limits Exceeded

What Does OA-198 Mean?

OA-198 appears in coordination of benefits scenarios where the authorization limit was exceeded and the adjustment is being passed between payers. The primary payer denied the excess services, and the adjustment is flowing to the next payer in the billing sequence.

CARC 198 signals that the precertification, authorization, notification, or pre-treatment requirements were exceeded — not missing, but surpassed. An authorization was in place, but the services delivered went beyond its scope. This could mean more visits than approved, more units than authorized, treatment dates outside the authorization window, or medication quantities above the pre-approved amount.

This denial is particularly common in therapy practices (physical therapy, occupational therapy, speech therapy) where initial authorizations cover a limited number of sessions and the patient's condition requires additional treatment. It also appears in behavioral health settings with session caps, DME orders that exceed quantity limits, and surgical cases where intraoperative findings require additional procedures beyond the original authorization scope.

The group code determines who absorbs the financial impact. Under CO, the provider is responsible because the contract required the provider to obtain additional authorization before exceeding the limit. Under PR, the patient is responsible when they have exhausted their plan's benefit limit for that service type (e.g., 20 PT visits per year). The distinction matters because CO means you cannot bill the patient, while PR means you should bill the patient directly.

How to Resolve

Verify which services exceeded the authorization, request a retroactive extension, and appeal if the extension is denied.

1. Check secondary payer authorization Verify whether the secondary payer has its own authorization in place and whether the excess services fall within the secondary payer's approved scope.
2. Submit to secondary payer Forward the claim with the primary ERA to the secondary payer for adjudication under their authorization and benefit limits.
3. Allocate remaining balance After all payers have adjudicated, assign any remaining balance to the patient or write off per contractual terms.

How to Prevent OA-198

• Track authorization limits separately for each payer when patients have multiple insurance plans
• Coordinate reauthorization requests with both primary and secondary payers simultaneously

Also Filed As

The same CARC 198 may appear with different Group Codes:

Related Denial Codes