CO-197 — Precertification/authorization absent
Also seen as: CO-197, PR-197
What it means
The plan required prior authorization for this service and it wasn't on file. Some plans allow a retro-authorization or an appeal, especially if the service was urgent or auth was requested and mishandled.
Standard definition (paraphrased): The payer's records show none of the required advance sign-off — getting authorization, notifying the plan, or a pre-treatment review — was completed before this service.
Why it happens
- • The service required prior auth and none was obtained
- • An authorization existed but for different dates, units, or CPT
- • The plan requires notification for behavioral-health services and it wasn't given
Common next steps therapists take
- • Check whether the service required prior auth and whether one exists for the right dates/units
- • Ask the plan about a retroactive authorization or an exception process
- • Many practices file a prior-authorization appeal when auth was warranted
A blank appeal-letter template is available for this kind of denial — Prior-authorization / retro-authorization appeal.
Educational information only
This page is general educational information, not legal, billing, or medical advice, and not a determination about any specific claim. Denial codes are maintained by the X12 committee and updated periodically. Always verify code meanings, benefits, and requirements directly with the payer and against your own records.
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