CARC 243 Active

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

TL;DR

The patient owes because PCP authorization was not obtained. Collect from the patient.

Action
Collect from Patient
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-243 Mean?

With PR, the patient is responsible because they did not obtain the required PCP authorization before receiving the service. Collect from the patient.

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

Cause Frequency
Patient obtained services without required PCP authorization The patient bypassed the required PCP authorization process and the unauthorized services are assigned to the patient Most Common
Patient self-referred without plan approval The patient self-referred to a specialist without obtaining required plan authorization Common

How to Resolve

  1. Try to obtain retroactive authorization Check if the PCP can provide a retroactive authorization.
  2. Communicate with the patient If authorization cannot be obtained, inform the patient of the charges.
  3. Collect from the patient Send a statement and collect.
Do Not Appeal This Code

The services were not authorized by the patient's network or primary care provider as required by the plan. The patient is financially responsible for these unauthorized services.

How to Prevent PR-243

General Prevention

Also Filed As

The same CARC 243 may appear with different Group Codes:

CO-243 OA-243

Related Denial Codes

PR-39 — Services Denied at Authorization/Pre-certification PR-61 — Failure to Obtain Second Surgical Opinion PR-95 — Plan Procedures Not Followed PR-197 — Precertification/Authorization/Notification Absent PR-198 — Precertification/Authorization Limits Exceeded

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
  3. https://www.aapc.com/resources/claim-adjustment-reason-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.