Prior Authorization

Prior authorization is the payer's requirement to approve a service before you provide it; missing or mismatched auth (CARC 197) is one of the most common denials, and a large share are recoverable.

Prior authorization (also 'precertification' or 'preauth') is a payer requirement that certain services be approved in advance, before you deliver them. When the auth is missing, obtained for the wrong code, or not linked to the claim correctly, the payer denies with CARC 197 ('precertification/authorization absent') — one of the highest-volume denials in every practice. The critical point is that a CARC-197 denial is often not a true no. Many are recoverable: the service may have been emergent or an add-on where auth wasn't practical; an auth may have existed but wasn't tied to the claim; or the payer's own record of the auth may be wrong. Retroactive authorization, proof the service was urgent, or simply linking an existing auth to the claim overturns a large share of these. Prior-auth denials also cluster — around specific high-cost procedures, drugs, and imaging — so the dollars concentrate where the payer requires auth most aggressively. For a practice, the leverage is knowing which CARC-197 denials are winnable and working those rather than writing the whole category off as a front-end failure. Retro-authorization, in particular, is an underused path that recovers claims practices assume are dead.

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