CARC · CO group
CO-197
Precertification, authorization, or notification absent
Contractual obligation; provider write-off unless appealed
- What it means
- Required prior authorization was not obtained or not on the claim.
- Likely cause
- Authorization expired mid-episode, unit count exhausted, or the auth number was never attached to the claim.
- How to fix it
- Request retro-authorization immediately because many payers allow a short window. Add an auth expiry alert to scheduling.
- Revenue impact
- Sometimes recoverable retroactively; almost always preventable.
- authorization
- prevention
- appeal
Related codes
- CO-50Non-covered service, not deemed a medical necessity
- CO-97Benefit for this service is included in the payment for another service already adjudicated
- CO-119Benefit maximum for this time period or occurrence has been reached
- CO-151Payer deems the information submitted does not support this many services
Early access
Seeing a lot of these?
Repeated CO-197 adjustments usually point to a step before submission. First Pass Paid is building pre-submission checks and a denial worklist to catch these earlier.
Join the early access list