CARC 243: Services not authorized by network/primary care providers
Your plan required a referral or authorization from your primary care provider, and it wasn't on file.
What this means for your claim
In gatekeeper plans (HMO/POS), specialist and certain services must be referred or authorized by your PCP. Without that referral, the claim is denied even if the specialist is in-network.
What to do next
- 1
Ask your primary care provider whether a referral was issued and whether it was submitted to the insurer.
- 2
If a referral should have been on file, ask your PCP to submit it retroactively and request claim reprocessing.
- 3
If you reasonably believed a referral wasn't needed, document the circumstances and file an appeal.
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