Retro-Authorization

Retro-authorization is obtaining a payer's approval for a service after it was delivered — the recovery path for many prior-auth (CARC 197) denials, within the payer's retro window.

Retro-authorization (retroactive authorization) is the process of getting a payer to approve a service after the fact, when a required prior authorization wasn't obtained beforehand. Payers allow it in defined circumstances and within a limited window: emergent or urgent services where prior auth wasn't feasible, cases where eligibility was retroactively established, or situations where the clinical need is clearly documented. It's the primary recovery path for a CARC-197 denial when there genuinely was no prior auth — instead of writing the claim off, you request retro-auth with the clinical documentation that justifies the service. The catch is timing and process: each payer has its own retro-auth window (often tight) and its own required forms and clinical criteria, so the request has to be built correctly and filed fast. Not every CARC-197 denial qualifies for retro-auth — some are better recovered by linking an existing auth or proving the service was emergent — but for the subset that does, retro-authorization turns an apparent dead end into a paid claim. Practices under-use it because it takes time to assemble the clinical justification and track the deadline, so these claims tend to sit until they age out.

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