AGAR Guide

Authorization

AR Guide Knowledge

Missing, expired, or incorrect prior authorization, precertification and pre-treatment review requirements.

Denial Decoder

Run this denial through the decoder

Enter the codes from your ERA/EOB and get this workflow with the exact CARC/RARC on your line.

Open Denial Decoder

Check first

Check these before anything else

  • Authorization number on file
  • Authorization dates of service
  • Service and provider match the authorization
  • Whether authorization was actually required (benefit design)
  • Whether retro-authorization is possible
  • CARC 197 / 15 / 210 and the accompanying remark code

Verify payer-specific rules: Heads up

Authorization requirements, valid channels, and retro-authorization options are payer- and plan-specific. Confirm the requirement for the exact service, date and provider with the payer before appealing.

AR Guide knowledge

What it means

The payer requires approval before certain services are rendered. The denial means the authorization was absent, expired, not on file, or did not match the services, dates, or provider billed. Some payers allow retro-authorization after the fact; others require an appeal with clinical justification.

AR Guide knowledge

Common causes

  • Authorization not obtained before the service
  • Authorization number on the claim did not match the service, date, or provider
  • Authorization expired before the date of service
  • Required notification or pre-treatment review was not submitted
  • Authorization obtained but not attached to the claim

AR Guide knowledge

What AR should verify

  • Pull the authorization record and compare number, dates, services, and provider
  • Confirm the authorization covered the date of service
  • Check whether the payer offers retro-authorization for already-rendered services
  • Verify the authorization was submitted on the claim correctly
  • Confirm the authorization requirement for the specific service

Recommended workflow

What to do next

  1. If a valid authorization exists, appeal with the authorization reference
  2. If the service is already rendered, request a retro-authorization or appeal with clinical necessity
  3. If not yet rendered, obtain authorization before the service
  4. Attach the authorization number at claim entry for future claims

Don’t assume

Avoid these shortcuts

  • An authorization exists just because one was requested
  • The authorization covers everything billed — check services, dates, and provider
  • Authorization and notification are the same thing
  • A denial means the service was never approved — check the authorization record first
  • The payer accepts retro-authorization for every service

AR Guide knowledge

Documentation

  • Authorization reference number and approval details
  • Authorization request and response timestamps
  • Clinical justification for the service
  • Payer correspondence showing the requirement

AR Guide knowledge

Escalation

  • Eligibility: confirm whether authorization is a benefit requirement
  • Clinical: obtain supporting medical necessity documentation for the appeal
  • Appeals: when a valid authorization was issued but the claim was denied
  • Supervisor: when the payer's authorization process is unclear or inconsistent

QA checkpoint

Confirm before closing

  • Verify authorization requirements at scheduling, not after the denial
  • Track authorization expiration dates and service limits
  • Attach the authorization number to the claim at entry

AR Guide knowledge

Related guides

ReferralEligibility & CoverageMedical Necessity

Reference

Related codes

Source & review

References

AR Guide editorial research · Last reviewed Aug 15, 2026 · Reviewed. General practice guidance — not official payer or standards documentation. Payer-specific requirements must be verified with the payer.

About this guidance: Note

AR Guide knowledge is general reference content written by our team — it is not payer-specific policy and never replaces the payer’s documentation or your contract. Always confirm specifics with the payer.