Referral Absent (CARC 288)

What it means

The payer denied the claim because it does not have a valid referral on file for the service billed. Many managed care plans (like HMOs) require a primary care provider referral before a patient sees a specialist or receives certain services, and this denial means that referral wasn't found or wasn't linked to the claim.

Common causes

No referral was obtained from the primary care provider before the service was rendered
Referral was obtained but not submitted with the claim or not on file with the payer
Referral number on the claim is missing, incorrect, or expired
Referral was issued for a different provider, specialty, or date range than what was billed
Plan requires referrals and front desk/staff did not verify this requirement before scheduling

How to fix it

Confirm whether the patient's plan requires a referral for the service/specialty billed
Contact the referring provider's office to verify a referral was issued and obtain the referral authorization number
Check the payer portal or call the payer to confirm the referral is on file and matches the date of service and rendering provider
Correct and resubmit the claim with the valid referral number in the appropriate claim field
If no referral exists, ask the PCP to submit one retroactively if the payer allows backdated or late referrals
Update front-office workflows to verify referral requirements before scheduling specialist visits

Appeal / resubmit

If a valid referral existed at the time of service, submit an appeal with a copy of the referral authorization, the referral number, and the referring provider's documentation showing it was issued prior to the visit. If the referral was obtained after the fact, include a letter explaining the delay and ask the payer whether retroactive referrals are accepted under the plan's policy. Always check the payer's specific timely filing and appeal deadlines before resubmitting.

Related codes

Frequently asked

Does this mean the patient wasn't eligible for the service?

Not necessarily. It means the payer's system didn't find a required referral on file, not that the service itself was non-covered. Correcting the referral information may resolve the denial.

Who is responsible for obtaining the referral — the specialist or the PCP?

Typically the referring (primary care) provider issues the referral, but the specialist's billing staff should verify it exists and is valid before or shortly after the visit.

Can a referral be submitted after the service date?

Some payers allow retroactive or backdated referrals within a certain window, but this varies by plan. Check the specific payer's policy.

More free billing tools: all denial codes · denial lookup · Medicare fee calculator

This content is informational only and does not constitute billing or legal advice. It does not guarantee any specific claim outcome or reimbursement.