OA-198: Precertification/Authorization Limits Exceeded
The authorization limit was exceeded during coordination of benefits. Check if another payer still has authorized visits available.
What Does OA-198 Mean?
With OA (Other Adjustments), the authorization limit was exceeded in a coordination of benefits context. One payer's authorized limit may differ from another's. Review each payer's authorization status and submit to the payer that may still have available authorized visits or units.
CARC 198 indicates that while a prior authorization was obtained, the services billed exceed the scope of that authorization. The provider may have delivered more visits or units than authorized, continued treatment beyond the approved date range, or prescribed a medication quantity that exceeds the approved amount.
Unlike CARC 197 (no authorization at all), CARC 198 means authorization existed but was exhausted or exceeded. This is common in therapy practices where patients use all their authorized visits, in ongoing treatment programs that extend beyond the approved duration, and in medication management where dosage or quantity changes were not reflected in an updated authorization.
Common Causes
| Cause | Frequency |
|---|---|
| Services exceeded approved authorization count The payer applies OA-198 when services exceeded the number of visits, units, or duration approved in the original prior authorization, signaling the provider to request an authorization extension | Most Common |
| Authorization expired before all services were delivered The prior authorization had a defined expiration date and services were rendered after the authorization period ended without renewal | Common |
How to Resolve
- Review each payer's authorization status Check the authorized limits for each payer in the COB chain.
- Submit to the payer with remaining authorization If one payer still has authorized visits, submit the claim to that payer.
- Request extension from the applicable payer Request additional authorized visits from the payer whose limit was reached.
- Appeal with medical necessity documentation Appeal to the payer that denied the claim with clinical justification for the additional services.
Appeal with documentation of medical necessity and clinical justification. Include physician notes, prior authorization records if applicable, and any relevant coverage policies that support the service. Reference the specific plan language or LCD/NCD that covers the service. For Medicare, file the redetermination within 120 days.
Common RARC Pairings
The RARC code tells you exactly what triggered the OA-198:
| RARC | Description |
|---|---|
| N386 | This decision was based on a National Coverage Determination (NCD) or Local Coverage Determination (LCD). Review the NCD or LCD to determine the authorized service limits and request an authorization extension → |
| N130 | Consult plan benefit documents/guidelines for coverage of this service. Check the plan authorization limits and request additional authorized visits or units before continuing treatment → |
How to Prevent OA-198
- Track authorization limits for each payer separately as approved quantities and durations may differ between primary and secondary plans
- Request authorization extensions from each payer before the original authorization limits are exhausted
- Monitor claim adjudication to detect when authorization limits are approaching across all payers
Also Filed As
The same CARC 198 may appear with different Group Codes:
Related Denial Codes
Sources
- https://x12.org/codes/claim-adjustment-reason-codes
- https://www.mdclarity.com/denial-code/198
- https://www.wcb.ny.gov/CMS-1500/WCB-CARC-RARC-codes.pdf
- https://www.aapc.com/resources/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.