243Denial Code (CARC)Active
CO 243 Denial Code: Services Not Authorized - Fix Tips
Code 243 means that the services billed were not authorized by the network or primary care providers. This indicates a lack of required pre-authorization or referral, leading to denial of payment.
Who Pays: Group Code Liability
Typically, code 243 results in a CO adjustment, meaning the provider must write off the charge and cannot bill the patient. However, if the patient failed to follow plan rules, it may be a PR responsibility, allowing billing to the patient.
Why Claims Get Code 243
- Service was provided without obtaining prior authorization from the network provider.
- Patient did not receive a necessary referral from their primary care provider.
- The claim was submitted with the wrong authorization number or no authorization number.
- The patient used an out-of-network provider without following plan requirements.
- The referral was not on file with the payer at the time of claim processing.
How to Fix & Resubmit
- Verify if the service required authorization or a referral based on the patient's insurance plan.
- Check the claim to ensure the correct authorization number was included, if applicable.
- Contact the payer to confirm if an authorization or referral was received and logged properly.
- If authorization was missed, request a retroactive authorization from the payer, if the plan allows.
- Submit a corrected claim with the appropriate authorization details if initially omitted.
Corrected Claim or Appeal?
For code 243, a corrected claim may be submitted if the authorization or referral was initially omitted. If denied due to lack of authorization, an appeal may be necessary if retroactive authorization is possible.
Preventing Future 243 Denials
- Ensure all services requiring authorization are flagged during scheduling and verified prior to service.
- Implement a system to track referral and authorization numbers and ensure they are included in claims.
- Regularly train staff on payer-specific authorization and referral requirements.
- Use eligibility checks to confirm network and primary care provider requirements before services are rendered.