Prior-authorization / retro-authorization appeal

For a claim denied because prior authorization was absent (CARC 197). Use it to request a retroactive authorization or to appeal when auth was warranted or mishandled.

The letter

[DATE]

[PAYER NAME]
Attn: Appeals / Utilization Management

Re: Appeal of authorization denial
Patient: [PATIENT NAME]
Date of birth: [PATIENT DATE OF BIRTH]
Member ID: [MEMBER ID]
Claim number: [CLAIM NUMBER]
Date(s) of service: [DATE(S) OF SERVICE]
Procedure code(s): [CPT CODE(S)]

To whom it may concern:

The above claim was denied for absent precertification/authorization (reason code [DENIAL CODE FROM THE REMITTANCE]) on the remittance dated [REMITTANCE DATE]. I am requesting reconsideration and, if applicable, a retroactive authorization.

[EXPLAIN THE CIRCUMSTANCES — for example, whether an authorization was requested and its outcome, whether the service was urgent, or why authorization was not obtained before the service.]

Diagnosis: [DIAGNOSIS AND ICD-10 CODE]

I have enclosed [LIST ANY SUPPORTING DOCUMENTATION]. Please review this request and reprocess the claim. I can be reached at [PROVIDER PHONE].

Sincerely,

[PROVIDER NAME AND CREDENTIALS]
NPI: [PROVIDER NPI]
[PROVIDER ADDRESS]
[PROVIDER PHONE]