How do I fix or resolve code 198?

Verify the authorization details — approved units, date range, and covered CPT codes — by checking the payer portal or the authorization approval letter. Compare the authorized units and date range against the services billed on the claim to identify the specific discrepancy (extra units, out-of-range date, or unauthorized procedure). If the service genuinely exceeded the authorization (e.g., additional units were medically necessary), request an authorization amendment or additional authorization from the payer with clinical justification for the additional services. If the authorization was incorrectly applied — for example, the units were within the authorized limit but the payer's system miscounted — file a claim reconsideration with the authorization approval documentation showing the correct unit count. If the authorization cannot be extended and the appeal is denied, write off the non-authorized portion as a provider adjustment or bill the patient if permitted by the plan.

198Denial CodeGeneral Adjustment

Code 198

Problem Description

Precertification/notification/authorization/pre-treatment exceeded.

Root Cause

The precertification, notification, authorization, or pre-treatment that was obtained exceeded the approved limits. Unlike CO-197 (where authorization was absent), CO-198 means an authorization was obtained but the service rendered exceeded the scope of what was authorized — for example, more units were billed than authorized, the service was rendered on a date outside the authorization date range, or the procedure performed was beyond what the authorization covered. The payer's system cross-references the authorized units, date range, and CPT codes against the claim and denies the portion that exceeds the authorization.

Resolution Steps

1Verify the authorization details — approved units, date range, and covered CPT codes — by checking the payer portal or the authorization approval letter.
2Compare the authorized units and date range against the services billed on the claim to identify the specific discrepancy (extra units, out-of-range date, or unauthorized procedure).
3If the service genuinely exceeded the authorization (e.g., additional units were medically necessary), request an authorization amendment or additional authorization from the payer with clinical justification for the additional services.
4If the authorization was incorrectly applied — for example, the units were within the authorized limit but the payer's system miscounted — file a claim reconsideration with the authorization approval documentation showing the correct unit count.
5If the authorization cannot be extended and the appeal is denied, write off the non-authorized portion as a provider adjustment or bill the patient if permitted by the plan.

EHR Documentation Note

Claim denied 198 — authorization exceeded; verified authorized units/date range, requested authorization amendment for additional services, or filed reconsideration for miscounted units.

Preventative Action

Track authorized units and date ranges in the practice management system and alert clinical staff when a patient is approaching the authorization limit so an extension can be requested before the service is rendered.

Related Codes in General Adjustment

Deductible Amount

Coinsurance Amount

Co-payment Amount

The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.