CARC 243CO · Contractual Obligation
The service required authorization from the patient's network or primary care provider, which wasn't obtained.
- Common causes
- An HMO or managed care plan requires primary care provider referral authorization for specialist or other services, and it wasn't secured beforehand.
- Suggested fix
- Obtain a retroactive referral or authorization if the payer allows it, or appeal with documentation of medical necessity.
Related Contractual Obligation codes
107This claim depends on another related claim or service being referenced, but that link wasn't provided.11The diagnosis code doesn't support medical necessity for the procedure billed, based on the payer's coverage edits.13The claim shows a date of service after the patient's recorded date of death.146The diagnosis code billed wasn't a valid, active code as of the date of service.150The documentation submitted doesn't justify the complexity or level of the service billed, commonly seen with evaluation and management visit levels.16The claim is missing required information or contains a billing error that prevented the payer from processing it.170This payer doesn't reimburse this specific provider type for this service.171This payer doesn't cover this service when it's billed by this provider type in this particular facility setting.
Frequently asked questions
What does CARC 243 mean?
The service required authorization from the patient's network or primary care provider, which wasn't obtained.
How do I resolve CARC 243?
Obtain a retroactive referral or authorization if the payer allows it, or appeal with documentation of medical necessity.
Why does CARC 243 happen?
An HMO or managed care plan requires primary care provider referral authorization for specialist or other services, and it wasn't secured beforehand.
CARC codes maintained by X12 (x12.org). Descriptions on this site are original reference interpretations. Always verify codes with authoritative sources before making billing decisions.