CARC 39
Authorisation was requested and refused
The payer declined authorisation at the time it was asked for, and the service went ahead anyway.
Why you actually get this
- The service proceeded before the authorisation decision came back.
- The refusal was received but did not reach the person scheduling.
- A peer-to-peer review was available and not pursued.
How to check whether it’s correct
- 01Find the authorisation request and the payer's response.
- 02Establish whether a peer-to-peer or reconsideration route was offered.
- 03Confirm whether the patient was informed before the service was delivered.
Sometimes worth appealing
Where the clinical case is strong and a peer-to-peer was never pursued, there is often still a route. Where authorisation was properly refused and the service proceeded regardless, the loss is usually the practice's.
Often arrives with
Seeing a lot of these?
A single denial is a claim to work. A pattern of the same denial is a process to fix, and the two need completely different responses. A free panel reads ninety days of your claims data and shows which codes actually recur for you.
Claim Adjustment Reason Codes are maintained by X12 as External Code List 139. The official description of this code is theirs and is not reproduced here. Check the authoritative list for current wording and status.