PR-198: Precertification/Authorization Limits Exceeded

What Does PR-198 Mean?

PR-198 means the patient has exhausted their plan's benefit limit for the service type. Unlike CO-198 where the provider missed an authorization step, PR-198 reflects that the plan itself caps coverage (e.g., 20 physical therapy visits per benefit year) and the patient has used their entire allotment. The patient is financially responsible for any additional services beyond the plan cap.

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.

Common Causes

How to Resolve

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

1. Verify the benefit limit Check the patient's plan documents or run an eligibility inquiry to confirm the annual or per-incident limit for the service type and how many have been used.
2. Inform the patient of their responsibility Contact the patient to explain that their plan's benefit limit has been reached and that additional services are their financial responsibility.
3. Generate a patient statement Bill the patient for the services that exceeded their plan limit with a clear explanation of the charges.
4. Offer payment arrangements For larger balances, offer a structured payment plan and provide any available financial assistance information.

How to Prevent PR-198

• Check the patient's remaining benefit allotment before every session and inform them when they are approaching the limit
• Discuss financial responsibility with patients in advance when their authorized sessions are running low
• Provide patients with written estimates of out-of-pocket costs for services beyond their plan's coverage cap

General Prevention

• Inform patients before each visit how many authorized sessions remain and when the authorization will expire
• Discuss financial responsibility with patients before continuing treatment beyond the authorized limit
• Provide patients with estimated out-of-pocket costs for services that exceed their authorization

Also Filed As

The same CARC 198 may appear with different Group Codes:

Related Denial Codes