OA-243: Services Not Authorized by Network/Primary Care Providers

What Does OA-243 Mean?

With OA, the PCP authorization issue was flagged during coordination of benefits.

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

How to Resolve

1. Obtain authorization Get the PCP authorization for the service.
2. Resubmit Add the authorization and resubmit.

How to Prevent OA-243

• Verify PCP authorization requirements for all payers in the COB chain

General Prevention

• Verify authorization requirements across all payers

Also Filed As

The same CARC 243 may appear with different Group Codes:

Related Denial Codes