PR-243: Services Not Authorized by Network Provider
The patient did not get the required referral or authorization. Help them obtain a retroactive referral, or bill them for the unauthorized services.
What Does PR-243 Mean?
PR-243 means the patient is responsible because they did not obtain the required referral from their primary care provider or the services they received were not authorized under their plan. The patient either bypassed the referral requirement or exceeded their authorized visits.
CARC 243 is an authorization denial. The payer has determined that the services rendered were not authorized by the patient's network or primary care provider. This can mean prior authorization was never obtained, the authorization expired before services were rendered, the authorization was for a different service than what was performed, or the patient did not get the required referral from their PCP. This code replaced the older deactivated CARC 38.
Unlike CARC 242 (which focuses on whether the provider is in-network), CARC 243 focuses on whether the specific service was approved. A provider can be fully in-network and still trigger this code if authorization was not obtained for the particular procedure or visit. The financial responsibility depends on who was responsible for obtaining the authorization — if the provider was contractually required to get prior auth and failed to do so (CO), the provider absorbs the cost. If the patient was required to get a referral (PR), the patient is responsible.
Retroactive authorization is often possible with strong clinical documentation supporting medical necessity. Many payers have specific timeframes for retroactive auth requests, and emergency situations typically have extended or waived auth requirements.
Common Causes
| Cause | Frequency |
|---|---|
| Patient did not obtain required referral The patient's plan requires a referral from their primary care physician for specialist services, but the patient sought care without first obtaining the referral, making them financially responsible | Most Common |
| Patient exceeded authorized number of visits The patient received more visits or services than were authorized by their plan, and the excess services are the patient's responsibility to pay | Common |
| Patient received non-covered service without authorization The service is excluded from the patient's coverage or requires specific authorization that was not obtained, and the patient elected to receive the service knowing or unknoring it was not authorized | Common |
How to Resolve
Determine why authorization was missing, pursue retroactive authorization or referral if possible, resubmit with authorization information, or assign responsibility to the appropriate party.
- Explain to the patient Contact the patient to explain that their claim was denied because authorization or referral was not obtained and they are financially responsible.
- Pursue retroactive referral Help the patient contact their PCP to request a retroactive referral. If obtained, resubmit the claim with the referral information.
- Bill the patient If retroactive authorization cannot be obtained, bill the patient for the full amount of the unauthorized services per your billing policy.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-243:
| RARC | Description |
|---|---|
| N574 | Our records indicate no prior authorization was obtained for this service. |
| N657 | Services were not authorized by the network or primary care provider. |
How to Prevent PR-243
- Verify patient authorization and referral status at every visit, not just the first
- Educate patients about their plan's referral and authorization requirements at registration
- Notify patients when their authorized visits are running out
- Help patients navigate the referral process by contacting their PCP office on their behalf
General Prevention
- Educate patients at registration about their plan's authorization and referral requirements
- Verify patient's referral and authorization status at every visit, not just the initial appointment
- Provide patients with advance notice when their authorized visits are running out
- Help patients navigate the referral process by contacting their primary care provider's office on their behalf
Also Filed As
The same CARC 243 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/243
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.