How do I resolve a CO-243 denial?

Pull the original claim and review the denial reason and any RARC codes Research the payer's policy for CARC 243 to understand the basis for denial See full resolution steps at tryarceum.com.

Can I appeal a CO-243 denial?

Yes. Most CO-243 denials can be appealed within 60-180 days depending on payer. This code is appealable if authorization was obtained but not recorded by the payer, if the service was urgent/emergent and did not require prior authorization, or if documentation proves authorization requirements were met. Use our free tool to generate an appeal letter.

CARC Code

243

🔴 Hard Denial

Services Not Authorized by PCP

The services provided were not approved or referred by the patient's primary care physician or network provider as required by the health plan. The claim is denied because proper authorization was not obtained before services were rendered.

authorization

Resolution: 35%Hard difficulty21-45 days avg

How to resolve this denial

Which payer denied this claim?

Review plan benefits; appeal with clinical necessity or bill patient for non-covered service

1
Pull the original claim and review the denial reason and any RARC codes
2
Research the payer's policy for CARC 243 to understand the basis for denial
3
Gather supporting documentation addressing the denial reason
4
Submit a formal appeal with the documentation within the plan's appeal window
5
Follow up on the appeal within 30 days and document all communication

Resolve this denial →

▶✓ Pre-action checklist — verify before contacting the payer

Review the full remittance advice (ERA/EOB) for additional RARC codes that explain the denial.
Verify the claim was submitted with correct patient eligibility and benefit information.
Check if this denial applies to a specific line item or the entire claim.

▶More about CO-243 — stats, related codes, appeal template

35%

Recovery Rate

21-45 days

Avg. Resolution

Hard

Difficulty

Occasional

Frequency

Payer-Specific Notes

How major payers handle CARC 243 by specialty.

Blue Cross Blue Shield

BCBS requires appeal submission within 180 days for most plans.

Appeal Letter Template

Generic appeal template for CARC 243 denials.

We are submitting a formal appeal for claim [CLAIM_NUMBER] for patient [PATIENT_NAME], date of service [DOS]. This claim was denied/adjusted with CARC 243 indicating: "Services not covered based on patient's current benefit plan.." We have reviewed the claim and are providing the attached documentation to support reconsideration. [SUPPORTING_DOCUMENTATION]. Please reconsider payment per the terms of our contract.

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