PR-39: Services Denied at Pre-Certification

What Does PR-39 Mean?

PR-39 indicates the authorization failure is the patient's responsibility, typically because the patient's plan requires a referral from their primary care physician and the patient did not obtain one before the visit. This pairing is less common than CO and appears primarily with HMO-style plans that mandate PCP referrals for specialist services.

When CARC 39 appears on a remittance, the payer is telling you that the service was denied at the authorization or pre-certification stage. This is not a standard "missing auth" code — it specifically means the authorization process was initiated (or should have been) and the payer said no. The service was either performed without authorization, performed after the auth request was denied, or performed with an expired or mismatched authorization.

This denial differs from CARC 38 (which typically covers services performed without any authorization attempt). CARC 39 focuses on situations where the pre-certification process was engaged and the outcome was unfavorable. The most frequent scenario is a provider submitting a prior auth request that the payer denied based on medical necessity criteria, followed by the provider performing the service anyway and submitting a claim. Less commonly, it appears when the authorization was obtained for a different procedure or expired before the service was rendered.

Under CO, this is the provider's financial responsibility. Many CO-39 denials are appealable — if you have strong clinical documentation demonstrating medical necessity, including physician notes, test results, and relevant clinical guidelines, a well-constructed appeal can overturn the denial. The key is providing evidence that the payer's initial medical necessity determination was incorrect. For emergency or urgent situations, most payers have a retroactive authorization process with a 48-72 hour submission window that should be used before the denial is issued.

Common Causes

How to Resolve

Determine whether the authorization was missing, denied, or mismatched — then either appeal with clinical evidence, obtain retroactive auth, or write off the balance.

1. Confirm the referral requirement Verify with the payer that the patient's plan requires a PCP referral for this service type and that no referral was on file at the time of adjudication.
2. Help the patient obtain a retroactive referral Contact the patient and their PCP to request a retroactive referral if the payer allows it. Some payers accept retro-referrals within a specific timeframe. If obtained, resubmit the claim.
3. Bill the patient if no referral can be obtained If the payer does not accept retroactive referrals, transfer the balance to patient responsibility. Explain that their plan requires a referral for this service and that future visits will need one.

How to Prevent PR-39

• Verify referral status at scheduling — do not confirm appointments for referral-required services without a valid referral on file
• Check referral status again at check-in and reschedule if the referral has not been obtained
• Educate patients with HMO plans about their referral requirements during registration and provide their PCP's contact information

General Prevention

• Inform patients at scheduling whether their plan requires a referral and that services without a referral may not be covered
• Verify referral status during check-in and reschedule the appointment if the referral has not been obtained
• Provide patients with their PCP's contact information and clear instructions on how to obtain a referral before their appointment

Also Filed As

The same CARC 39 may appear with different Group Codes:

Related Denial Codes