Denial category

BCBS Prior authorization denials: Codes, Appeals and Fix Workflow

BCBS prior authorization denial workflows for absent, exceeded, expired, or mismatched authorization and referral issues.

Category summary: Match the authorization record to the member, provider, service, location, date span, units, and billed code.

Top codes in this category

CO-15Authorization number missing, invalid, or not applicable CO-39Services denied when authorization was requested CO-197Precertification, authorization, notification, or pre-treatment absent CO-198Precertification, authorization, notification, or pre-treatment exceeded CO-210Precertification or authorization not received timely CO-243Services not authorized by network or primary care providers CO-284Authorization number may be valid but does not apply to billed services CO-287Referral exceeded CO-288Referral absent CO-302Authorization or notification time limit expired

How to work these denials

Locate the exact authorization/referral requirement for the member plan and service type.
Match the auth record to claim fields: member, CPT/HCPCS, diagnosis, provider, facility, dates, units, and place of service.
If the auth was omitted from the claim, follow corrected-claim rules and include the authorization number.
If the auth existed but was misapplied, appeal with screenshots, approval letter, call reference, and timeline.
For BlueCard claims, confirm whether the local/host plan or member/home plan handled the authorization workflow.

Evidence checklist

Authorization approval
Referral record
Portal screenshot
Call reference number
Claim image
Medical records if clinical criteria are disputed

Guides in this cluster