Denial code

CO 197 denial code, authorization found and paid

CO 197 means no authorization was on file. Locate the approval, attach it and send the claim again.

A CO 197 denial means the payer found no precertification, authorization or notification tied to the service. The fix starts with one question: did an approval exist? If it did, the claim needs the reference. If it did not, the claim needs a different path.

What CARC 197 says
Precertification/authorization/notification/pre-treatment absent. X12 reason codes
Group code CO
Contractual Obligation. X12 group codes
Claims with no decision
Under the Medicare Part B ASC prior authorization demonstration, claims without a decision are held for prepayment review. Noridian, ASC prior authorization claims
Non affirmed decisions
Under the same demonstration, claims with a non affirmed decision are denied, and the provider may appeal or bill secondary insurance. Noridian, ASC prior authorization claims
Where the tracking number goes
The 14 byte Unique Tracking Number from the decision letter goes on the claim: loop 2300 REF segment on an 837 professional claim, item 23 on paper. Noridian, ASC prior authorization claims

In the official words

Precertification/authorization/notification/pre-treatment absent

X12

Claims with a non-affirmed PA decision will be denied.

Noridian Healthcare Solutions

Find out whether an approval exists

CO 197 can mean the approval was never requested, or that it was granted and never reached the claim. Check the payer record and your own notes for an authorization number, the approved dates and the approved service before you do anything else.

Medicare shows how this works where prior authorization applies. In the Part B ambulatory surgical center demonstration, prior authorization is optional. A claim with no decision is held for prepayment review, and a claim with a non affirmed decision is denied. Rules differ by payer and by service, so check the one on your remit. Noridian

How to clear a CO 197 denial

Search the payer record and your files for an authorization number that covers the date of service.
If one exists, correct the claim so the number appears where the payer expects it, and send the claim again. In the Medicare demonstration, the Unique Tracking Number from the decision letter goes in the loop 2300 REF segment of an 837 professional claim, or in item 23 of a paper CMS 1500.
If none exists, ask the payer what it will accept after the fact and what proof it needs. Get the answer in writing.
If the payer made a non affirmed decision, Noridian says the provider may pursue appeal rights or submit the claim to secondary insurance where that applies. Once a claim is submitted after a non affirmation and denied, that denial becomes an initial determination that can be appealed.
Check the related services. In the demonstration, if a service requiring prior authorization is not paid, related anesthesiology, physician or facility services are denied too.
Log which step failed, so the next visit for this service is not scheduled before the approval is in the record.

If an ASC claim without a prior authorization decision goes to prepayment review, Noridian says the ASC has 45 days to answer the documentation request. The appeal and secondary insurance options come from Medicare contractor guidance for the ASC demonstration. Noridian

Stop CO 197 before it starts

Authorization denials are decided before the visit. The service, the payer and the date decide whether an approval is needed, and the number has to travel with the claim.

WeBill Health maintains internal payer rule libraries organized by specialty and by carrier, built and updated by people who work claims in your specialty every day. Every claim receives Human Expert Review against them before it goes out.

Sources

Denial Defense 2.0

Root cause denial work that closes the documentation gaps behind repeat denials before they disrupt your revenue cycle.

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payer rulesets in our rule libraries

See Denial Defense 2.0

Find the denials that keep coming back

The Revenue Defense Audit is a free, forensic review of your claims and A/R by the team that would work your account. It maps your denial patterns by payer and code, with the root cause behind each one.

Check my Revenue Defense Score for the denial exposure in your specialty.

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