PR-284: Authorization Valid but Not Applicable to Billed Services

What Does PR-284 Mean?

PR-284 means the patient received services outside the scope of their authorization and bears the financial responsibility. This typically occurs when the patient obtained services beyond what was originally approved without getting additional authorization.

CARC 284 indicates that the precertification, authorization, notification, or pre-treatment number provided on the claim may be valid — meaning it exists in the payer's system — but it does not cover the specific services that were billed. The authorization was issued for different procedures, different dates of service, a different provider, or a different scope of treatment than what appears on the claim.

This is a nuanced denial because the provider did obtain authorization, just not the right one for the billed services. Common scenarios include: using an authorization that covers some but not all of the billed procedure codes, submitting a claim for services performed after the authorization expired, billing additional procedures beyond what was originally approved, or simply entering the wrong authorization number due to a clerical error.

The distinction between CARC 284 and a standard no-authorization denial (such as CARC 197) is important: with 284, the payer acknowledges an authorization exists but identifies a mismatch between that authorization and the claim. This typically means the fix is achievable — either locate the correct authorization number, request retroactive authorization, or demonstrate that the existing authorization should cover the billed services.

Common Causes

How to Resolve

Identify the mismatch between the authorization and billed services, then either correct the authorization number, request retroactive approval, or appeal with supporting documentation.

1. Verify the authorization scope Confirm the denied services were indeed outside the authorization scope.
2. Communicate with the patient Inform the patient about services rendered outside their authorization and their financial responsibility.
3. Bill the patient Bill the patient for services not covered by the authorization.

How to Prevent PR-284

• Inform patients about authorization requirements and which services are covered before providing additional treatments
• Verify authorization coverage before expanding services beyond the original scope

General Prevention

• Inform patients about authorization requirements and what services are covered under their existing authorization
• Obtain confirmation from the payer before providing services that may fall outside the current authorization

Also Filed As

The same CARC 284 may appear with different Group Codes:

Related Denial Codes