How to appeal a prior authorization denial (CARC 197)
Before writing an appeal, check whether an authorization actually existed — mismatched authorization numbers, the wrong provider on the authorization, or a payer processing error cause many of these denials. When no authorization exists, ask whether the payer offers a retro-authorization path; when one does exist, the appeal presents the authorization record and asks for reprocessing.
What should you check before appealing?
Pull the authorization record and compare it to the claim: the authorization number, the authorized provider and site, the service codes, and the date range. If any of these were mismatched on the claim, the fix may be a corrected claim with the right authorization details rather than an appeal.
What if no authorization was obtained?
Ask the payer about retroactive authorization first — many plans allow it in defined circumstances, such as urgent services or situations where the practice could not have known authorization was required. If retro-authorization is refused, an appeal can still argue the service met the plan's own criteria.
What does a strong authorization appeal argue?
That an authorization existed and the claim matches it; or that the payer's own rules did not require one for this service and setting; or that the clinical situation met the plan's exception criteria. Attach the authorization record, the clinical notes, and the plan's published authorization requirements where they support you.