RemitBench/Denial codes/CO-197

CO-197 denial code

Code 197 says permission was needed and the payer does not have it. The care may have been perfect and necessary. The plan required a step before it, and that step is missing.

The code list's own wording: Precertification/authorization/notification/pre-treatment absent.

What it means: The plan requires approval before this service and has no record of it. The denial is about process, not about whether the treatment was appropriate.
Who owes the money: The practice, usually CO is the common pairing, which makes it a write-off. That is the payer's position: obtaining authorisation was your obligation under the contract, so the cost of missing it is yours. PR appears where the plan holds the patient responsible for using an unauthorised service, and your contract decides whether you may act on that.
Is appealing worth it: Often worth it, and the odds depend entirely on why it is missing. An authorisation that exists and was not linked to the claim is nearly always recoverable. One that was never requested is much harder, and rests on whether the payer allows a retrospective review.

Find out whether an authorisation exists before you do anything else. There are three different situations behind this code and they have completely different prospects: one was obtained and did not reach the claim, one was requested and refused, or none was ever sought. The first is administrative and usually recoverable. The third is the expensive one. Establish which you are in before you spend an hour on it.

Do not bill the patient on reflex. Under most participating contracts, obtaining authorisation is the practice's obligation, and charging the patient for your missed step is usually a contract breach. Read the letters and read the contract before a statement goes out.

Why the payer sent it

No authorisation was requested, because nobody knew the service needed one.
An authorisation exists and its number did not reach the claim.
The authorisation covered a different procedure code from the one billed.
The authorisation expired before the service was performed.
The authorised units or visits ran out, which is really CO-198.
The service was performed by a different provider from the authorised one.
The plan changed its authorisation list and nobody noticed.

Remark codes you will see with it

Remark code	What it adds
N54	The claim information is inconsistent with the pre-certified or authorised services.
N130	Read the plan document for the authorisation requirements. Its own page.
N30	The patient was ineligible for this service. See N30.

Remark code

What it adds

N54

The claim information is inconsistent with the pre-certified or authorised services.

N130

Read the plan document for the authorisation requirements. Its own page.

N30

The patient was ineligible for this service. See N30.

Read the letters in front of the 197

CO-197: Contractual obligation. Your write-off. The usual pairing, and the payer's way of saying this was your step to take.
PR-197: Patient responsibility. Seen where the plan holds the member responsible for using an unauthorised service. Check your contract before billing.
PI-197: Payer initiated. The patient owes nothing.

What to do next

Search for an existing authorisation

Portal first, then the phone. Search by patient and date range rather than by number, in case the number you hold is wrong.
If one exists: resubmit with the number attached. This is a corrected claim, it is quick, and it works. If it exists but names a different code: ask whether it can be amended. Many payers will amend rather than make you start again.
Ask whether the payer allows a retrospective review

Policies differ, and many allow one in defined circumstances such as an emergency, a system outage, or coverage that was loaded after the service. Ask what their policy is rather than assuming there is none.
If they do: submit the clinical documentation and explain plainly why authorisation was not obtained in advance.
Check the authorised details against the claim

Procedure code, provider, dates, units and site. A valid authorisation that does not match the claim produces the same denial as no authorisation at all.
Fix the list that let it through

The step that pays for itself. Every one of these means a service went ahead without a check that should have happened. Find out which payer and which procedure, and add it to the front desk list.

Codes that get mixed up with 197

Code	How it differs from 197
198	Authorisation was exceeded rather than absent. There was one and it ran out. See CO-198.
288	A referral is absent. A different permission, usually from another provider rather than the payer. See CO-288.
272	Coverage guidelines not met, which authorisation problems sometimes hide behind. See CO-272.
50	Not medically necessary. The payer looked at the care and disagreed. See CO-50.
95	Plan procedures not followed. The vaguer code that most often turns out to be this one. See CO-95.
15	The authorisation number is missing or invalid. An older code, deactivated, but still seen on legacy remittances.

The important difference is between 197 and 50. A 197 means nobody assessed the care. A 50 means somebody did and said no. An appeal against a 197 argues about process and an appeal against a 50 argues about medicine.

When not to appeal

The service clearly needed authorisation, none was requested, and the payer does not allow retrospective review. Write it off and fix the process.
The authorisation exists and matches. Then this is a resubmission, not an appeal.
The real problem is that units ran out, which is code 198 and a different argument.

Code 197 in dental

Dental plans mostly use predetermination rather than hard authorisation, and the difference matters. A predetermination is an estimate of what the plan would pay and is usually not required. Real authorisation requirements appear on managed care dental plans and on medical cross coded claims, and those are the ones that produce a 197.

Predetermination is not authorisation, and it is still worth doing

A predetermination does not guarantee payment and is not what a 197 is asking for. What it does is tell the patient, before treatment, what the plan is likely to cover. For crowns, implants, orthodontics and anything large, that conversation is much easier before the work than after a denial.

Where dental authorisation is real

Managed care dental plans, which often require approval for anything beyond basic care.
Medical cross coded procedures such as surgical extractions, sleep appliances and some implant work.
Orthodontic cases on plans that approve the case rather than the visits.
Hospital or sedation cases, where the facility side has its own requirement.

Questions people ask about CO-197

Can I get a retro authorisation after a CO-197?

Sometimes. Policies vary by payer, and many allow a retrospective review in defined situations such as an emergency, a system outage or coverage loaded after the service. Ask what that payer's policy is rather than assuming there is none, and include the clinical documentation and a plain explanation of why approval was not obtained in advance.

Can I bill the patient for a missing authorisation?

Usually not. Under most participating contracts, obtaining authorisation is the practice's obligation, so charging the patient for a step you missed is generally a breach. If the line arrives as PR, check the specific contract language before sending a statement.

What is the difference between CO-197 and CO-50?

A 197 means nobody assessed the care, because the required approval step never happened. A 50 means somebody did assess it and decided it was not medically necessary. The first is a process argument and the second is a clinical one.

Related codes

Back to all denial codes

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