Who has to pay after a code 243 denial?

Who owes depends on the details. The letters in front of the number matter: CO (contractual obligation) usually means an in-network provider must absorb it, while PR (patient responsibility) means the plan says you owe it.

How long do I have to appeal?

It depends on your coverage: 180 days for most employer and marketplace plans, 120 days for Original Medicare, about 90 days for Medicaid (varies by state), and only 65 days for Medicare Advantage. Set your deadline clock before you do anything else.

Denial code 243 · CO-243 / PR-243 · translated

Denial code 243: what it means — and how to fight it

Denial code 243 (shown on your EOB as CO-243 or PR-243) means: “Services not authorized by network/primary care providers.” In plain English: Your PCP or network gatekeeper didn't sign off before the care.

medium appealability Who owes depends on the details

What they're really saying

“Services not authorized by network/primary care providers.”

Your PCP or network gatekeeper didn't sign off before the care.

Your odds

Worth fighting — many of these get fixed.

Retro-referrals and gatekeeper-process failures reverse many of these.

Fewer than 1 in 100 denied claims are ever appealed. When people do appeal, roughly 4 in 10 win the first round — and independent external review overturns 40–50% of what reaches it.

How to appeal a code 243 denial

Decode. You just did — this page is step one.
Set your clock. 180 days for most employer and marketplace plans, 120 for Original Medicare, ~90 for Medicaid, only 65 for Medicare Advantage.
Urgent? If this is care you still need, call and request an expedited appeal — they must decide within 72 hours.
Call your PCP and ask for a retroactive referral. Get a retroactive referral from your PCP; if the plan's referral process failed you (unreachable PCP, urgent need), document that.
Send it certified. Letter plus evidence, keep copies of everything.
Escalate. Denied again? Independent external review — a doctor who doesn't work for your insurer decides.

Do it in minutes, free

The AppealClock tool translates your denial, drafts your appeal letter, computes your exact deadline — and watches the clock so you don't have to. No account. Your medical details never leave your device.

Start your appeal & set your clock →

Common questions

What does denial code 243 mean?: Your PCP or network gatekeeper didn't sign off before the care.
Can I appeal a CO-243 or PR-243 denial?: Yes. Appealing is free and it is your legal right. For this code the odds are medium: Retro-referrals and gatekeeper-process failures reverse many of these. Fewer than 1 in 100 denials are ever appealed — insurers count on silence.
Who has to pay after a code 243 denial?: Who owes depends on the details. The letters in front of the number matter: CO (contractual obligation) usually means an in-network provider must absorb it, while PR (patient responsibility) means the plan says you owe it.
How long do I have to appeal?: It depends on your coverage: 180 days for most employer and marketplace plans, 120 days for Original Medicare, about 90 days for Medicaid (varies by state), and only 65 days for Medicare Advantage. Set your deadline clock before you do anything else.