PR-198: Precertification/Authorization Limits Exceeded

What Does PR-198 Mean?

With PR (Patient Responsibility), the patient is financially responsible for services beyond the authorized limit. The patient chose to continue treatment after the authorized visits were exhausted, or the plan has a coverage cap that has been reached. Collect the balance from the patient.

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

How to Resolve

1. Verify the authorization limit Confirm that the patient's authorized visits or units were genuinely exhausted.
2. Review the patient's benefit plan Confirm the service limitation in the patient's plan.
3. Communicate with the patient Explain the financial responsibility clearly with documentation of the authorization limit.
4. Collect from the patient Send a statement and offer payment plan options if the balance is significant.

How to Prevent PR-198

• 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