Missing or Expired Authorization
CARC 197CARC 15The service needed prior authorization and the payer has no record of an approval.
What it is
The pattern
An authorization denial says the service required prior approval and the payer does not have a valid, timely authorization on file — or the authorization that exists is for a different service, date, or provider.
Why it happens
Common causes
- The service was scheduled after the authorization expired or the number of approved visits ran out.
- The rendering provider was not listed on the authorization.
- The authorization was requested under the wrong plan or member ID.
- The staff member assumed 'we've always done it this way' — and the payer changed its list of auth-required codes.
Prevention
Stop it before the claim goes out
- Check the payer's authorization requirements before scheduling, not at the front desk the day of service.
- Compare the authorization against the exact service code, DOS, provider, and visit count before rendering.
- Log authorization numbers and expiration dates on the account and re-verify when the DOS changes.
When it happens
What to do
If the service was rendered and the authorization is missing, check for retro-authorization or reconsideration options first — many payers allow a retro request within a stated window. If an authorization existed but was misapplied, appeal with the original approval number and evidence the service matched it.
Deeper dive
The full denial guide
The service required prior authorization, precertification, or pre-treatment review that was missing, expired, or did not cover what was billed.
Open the Authorization guide →