OA-243: Services Not Authorized by Network Provider

What Does OA-243 Mean?

OA-243 appears in complex authorization scenarios such as emergency services where authorization was not feasible, or transitional care situations where the authorization responsibility is unclear between parties.

CARC 243 is an authorization denial. The payer has determined that the services rendered were not authorized by the patient's network or primary care provider. This can mean prior authorization was never obtained, the authorization expired before services were rendered, the authorization was for a different service than what was performed, or the patient did not get the required referral from their PCP. This code replaced the older deactivated CARC 38.

Unlike CARC 242 (which focuses on whether the provider is in-network), CARC 243 focuses on whether the specific service was approved. A provider can be fully in-network and still trigger this code if authorization was not obtained for the particular procedure or visit. The financial responsibility depends on who was responsible for obtaining the authorization — if the provider was contractually required to get prior auth and failed to do so (CO), the provider absorbs the cost. If the patient was required to get a referral (PR), the patient is responsible.

Retroactive authorization is often possible with strong clinical documentation supporting medical necessity. Many payers have specific timeframes for retroactive auth requests, and emergency situations typically have extended or waived auth requirements.

How to Resolve

Determine why authorization was missing, pursue retroactive authorization or referral if possible, resubmit with authorization information, or assign responsibility to the appropriate party.

1. Assess emergency exceptions Determine whether the services were emergent, making authorization requirements waived or subject to retroactive approval within a specific timeframe.
2. Contact the payer Reach out to the payer to clarify why OA was used and what resolution paths are available, including emergency authorization or transitional care provisions.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-243:

How to Prevent OA-243

• Know your payer contracts' emergency authorization provisions and post-stabilization care rules
• Document emergency circumstances thoroughly to support retroactive authorization requests

Also Filed As

The same CARC 243 may appear with different Group Codes:

Related Denial Codes