Denial Code Inspector

CARC 197: Precertification/authorization/notification absent

RARC N479: Missing prior authorization

Category: Prior Authorization
Frequency: Common (top 10 denial reason)

Root Cause:
  The procedure was performed without obtaining prior
  authorization from the payer.

Action Plan:
  1. Check if retro-authorization is available for this payer
  2. Gather clinical documentation supporting medical necessity
  3. Submit retro-auth request if available
  4. If denied, file formal appeal with:
     - Letter of medical necessity
     - Clinical notes supporting the procedure
     - NCD/LCD reference if applicable

Payer-Specific (Medicare):
  Appeal Level: Redetermination
  Deadline: 120 days from denial date
  Where to file: MAC Jurisdiction 5

Payer-Specific (Commercial):
  Appeal Level: Internal appeal
  Deadline: 180 days (varies by plan)
  Where to file: Payer appeals department

curl -X POST https://api-dev.rcintell.com/v1/agents/denial-resolution \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "query": "Claim denied for prior auth",
    "carc": "197",
    "rarc": "N479"
  }'