PR-243 means the payer says the service wasn't authorized by the required network or primary care provider. The PR group assigns the adjusted amount to patient responsibility on the remittance. To resolve the denial, establish which permission the member's plan required for that service, whether a matching record exists, and whether the payer applied the right rule. A referral, a prior authorization and a prescription can answer different questions.
For a pharmacy medical claim, a missing-referral message may point to a record the plan didn't match or to a requirement that doesn't apply to the billed service. An equipment claim gives a concrete example: a plan can exclude DME from its PCP-referral rule while still requiring an equipment order or prior authorization. Adding a referral number won't resolve every PR-243 adjustment, and the PR label alone doesn't settle what the pharmacy may collect.
The three records serve different purposes
A plan referral directs a member to a specialist or specified service through the plan's required provider. The clinician's referral in a medical record may need a separate submission to the insurer or its delegated administrator. A note saying ‘referred’ isn't proof that the plan received the required record.
Prior authorization is the insurer's advance decision about the medical necessity of a service or item. A plan may require both a referral and prior authorization; one doesn't replace the other. An order for equipment documents what the practitioner prescribed and must satisfy the applicable DMEPOS order requirements. It doesn't by itself establish that the plan's referral or authorization process was completed.
The nearby reason codes also describe different findings. CARC 242 concerns who provided the service: network or primary care providers. CARC 243 concerns who authorized it. CARC 197 says precertification, authorization, notification or pre-treatment was absent. Read the actual reason and accompanying payer explanation before opening a generic ‘missing prior authorization’ task. Provider eligibility is a separate question covered in the B7 guide. CO-243 uses the same reason but assigns the adjustment to contractual obligation instead of patient responsibility; the actual group and plan terms matter.
An accompanying M115 remark instead describes an item supplied by a non-contract or non-demonstration supplier. If that appears beside PR-243, ask the payer to reconcile the supplier-status explanation with the authorization reason. A new PCP referral may leave that different problem unresolved.
A DME claim that the referral rule excludes
Consider a hypothetical pharmacy DME claim that returns PR-243 with a missing-PCP-referral explanation. The pharmacy has an equipment order, but no plan referral. Before requesting one, the biller verifies the patient's exact Medicare Advantage product, who administers referrals, the service date and the category the payer assigned to the claim.
Under UnitedHealthcare's standard 2026 Medicare Advantage referral policy, DME and diabetic testing supplies are among the excluded service categories. That example gives the biller a specific discrepancy to raise: ‘This claim is for DME, which the applicable referral policy excludes. Which service category and referral rule did you apply?’ The biller should also check whether the submitted code or provider information caused the claim to be matched to a different category. Correct inaccurate submitted facts; if those facts are accurate, request review of the applied rule.
This is a hypothetical PR-243 claim, not a statement that UnitedHealthcare uses that code for every referral denial. The exception belongs to the cited policy. Delegated administrators can use different processes, and existing referral arrangements in California, Nevada and Texas require checking the applicable delegate or member coverage document. An exemption from PCP referral also leaves separate coverage and prior-authorization requirements in place.
For pharmacy teams, this comparison applies to a medical-benefit claim. A prescription claim submitted to a pharmacy benefit manager has its own transaction and payer instructions; don't carry a medical referral fix into it. The medical-versus-pharmacy-benefit guide explains that routing distinction.
When the referral exists but the payer missed it
If the service does require a referral, compare the payer's actual referral record with the claim: the member, authorized specialty or provider group, effective dates and permitted visits must fit the service. UnitedHealthcare's current guidance illustrates why the matching rule matters. Its standard Medicare Advantage process matches claims to referrals without requiring the referral number on the specialist claim. An existing referral applies to providers of the same specialty billing under the same tax ID. Simply adding a number doesn't fix a wrong date, specialty or tax-ID match.
If a valid record covers the visit, send that record and the claim discrepancy through the payer's payment-review route. Keep its confirmation or reference number for that follow-up so the payer can locate the disputed submission. If the claim has an incorrect provider or date, correct the claim through the payer's instructions instead. The ERA guide helps locate the affected service line and complete payer explanation.
If no valid record exists, find out whether the governing plan permits a late submission or retrospective review. Don't backdate a clinical record or assume a new referral covers an earlier visit. For example, UnitedHealthcare's standard process permits a referral effective date up to five calendar days before entry; that limited option doesn't establish a general right to retroactive authorization. An unresolved requirement or disputed matching rule needs the billing lead's review before resubmission.
Before collecting the PR-243 amount
The adjustment group reports the payer's responsibility assignment. Confirm it against the plan's coverage decision, participation terms and applicable patient protections before sending a statement. For the cited UnitedHealthcare Medicare Advantage process, missing-referral denials are provider liability once enforcement begins. Its member-billing exception requires satisfying the noncovered-service rules, including a pre-service Integrated Denial Notice; an after-the-fact referral doesn't supply that notice.
UnitedHealthcare's current 2026 page also says it has extended the grace period for adverse payment decisions related to the new referral requirements. Verify the current notice and the rule for the service date before acting on an older May 1 enforcement date. If a PR assignment conflicts with those terms, keep collection on hold and use the payer's reconsideration or appeal process with the specific policy and record discrepancy. Use that plan's deadline, rather than treating PR-243 as a universal appeal timetable.
