Prior authorization denials are process failures: either the authorization wasn't obtained, it was obtained for the wrong service or date range, or it wasn't referenced correctly on the claim. The good news: many CARC 197 denials are recoverable once you understand exactly which scenario you're dealing with.
What the full brief covers
Signed-in members see the full brief. Here is what it contains.
- Determine which scenario you're in
- Scenarios A and D: corrected claim or appeal with the auth number
- Scenario B: retroactive authorization
- Scenario C: emergency or urgent care exception
- Writing the appeal
- Prevention: stop CARC 197 before it starts
- Prior authorization appeal letter template (fillable Word download)