CARC 197 Denial Appeal

Prior authorization absent

Precertification/authorization/notification/pre-treatment absent.

The winning argument

Where prior authorization is applied to routine behavioral-health services more stringently than to comparable medical/surgical services in the same classification, the requirement itself is an NQTL parity violation; alternatively, the care was clinically urgent or the auth was on file (administrative error).

• The service was a clinical emergency precluding prior authorization.
• Continuity-of-care protections apply to ongoing treatment.
• The plan must produce its comparative analysis showing auth requirements are applied comparably to med/surg.

Sample appeal letter body

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We are appealing the denial for {{patient_reference}} under CARC 197 (precertification absent). The behavioral-health services on {{dates_of_service}} addressed {{clinical_urgency}}. If this is treated as routine outpatient care, we request the plan's comparative analysis demonstrating that this prior-authorization requirement is applied no more stringently than for analogous medical/surgical outpatient services, as required under the Mental Health Parity and Addiction Equity Act. Absent that parity showing, this administrative denial is invalid and the claim must be reprocessed.