Prior Authorization on Medicare Denial Guide — Barley

Medicare Denied Claim: Prior Authorization Expired

Thu, 26 Mar 2026 00:00:00 +0000

What This Means

Your claim was denied because the prior authorization on file either expired before the service was provided or didn’t match the service that was actually performed. On your notice this usually appears as CARC code CO-198, “precertification/notification/authorization/pre-treatment exceeded” – the code plans use when an authorization was on file but the service that was billed went beyond what it covered. Even though your plan originally approved something, the approval wasn’t valid for what was ultimately billed.

Medicare Denied Claim: Referral Missing or Invalid

Thu, 26 Mar 2026 00:00:00 +0000

What This Means

Your claim was denied because your health plan required a referral from your primary care provider (PCP) for this service, and the referral was either missing, expired, or didn’t match the service you received. Without a valid referral on file, the plan won’t pay for the visit. On your notice, a missing or invalid referral is typically adjudicated under the authorization codes – CARC code CO-197, “precertification/authorization/notification/pre-treatment absent,” or, when a referral has expired or run out of visits, CO-198, “precertification/notification/authorization/pre-treatment exceeded.”

Medicare Denied Prior Authorization Request

Thu, 26 Mar 2026 00:00:00 +0000

What This Means

If you have Medicare Advantage, your plan reviewed a request for advance approval and denied it. You can ask the plan to reconsider before receiving the service. If you have Original Medicare, the contractor or review program may instead have issued a prior-authorization non-affirmation. That is a preliminary review decision, not a denied claim with the same appeal route.

For Original Medicare, ask your provider to review and resubmit the request. For example, CMS’s current WISeR operational guide permits resubmissions and a peer-to-peer review process. A non-affirmation itself is not appealable. If a claim is later submitted and denied, that claim decision can be appealed; the Original Medicare redetermination deadline is 120 days after receipt of the MSN, presumed five days after its date unless shown otherwise. The Medicare Advantage appeal instructions below apply to plan denials.

Medicare Denied: No Prior Authorization (Your Fix)

Thu, 26 Mar 2026 00:00:00 +0000

What This Means

Your claim was denied because the service required prior authorization — your plan’s advance approval — and none was on file; getting that approval is almost always your provider’s responsibility, not yours. On your notice this appears as CARC code CO-197, “precertification/authorization/notification/pre-treatment absent”. Do one thing now: call your provider’s billing office and ask them to request retroactive authorization from your plan — some plans allow it, especially in urgent situations, and it can clear the denial without a formal appeal. Pursue that alongside your appeal, not instead of it: no rule caps how long a plan may sit on a retroactive request, and waiting on one does not pause your appeal clock. You have 65 days from the date on your denial notice (Medicare Advantage) or 120 days from receiving your MSN (Original Medicare), and 80.7% of appealed Medicare Advantage prior authorization denials were fully or partially overturned in 2024.