CARC 197 Active

CO-197: Precertification/Authorization/Notification Absent

TL;DR

Provider bears this denial. Add the missing authorization number, pursue retroactive authorization, or appeal with medical necessity documentation.

Action

Verify & Resubmit

Who Pays

Provider

Appeal

Yes

Patient Impact

None

Disclaimer

This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does CO-197 Mean?

With CO (Contractual Obligation), the missing authorization is the provider's contractual responsibility. The provider cannot bill the patient for this denial. If authorization was obtained, add the number and resubmit. If not, pursue retroactive authorization or appeal with medical necessity documentation.

CARC 197 is one of the most common and costly denial codes in medical billing. It indicates that the service required prior authorization, precertification, or advance notification from the payer, and that requirement was not met before the service was rendered — or the authorization information was not included on the claim.

This denial can occur for several reasons: the authorization was never obtained, the authorization number was not included on the claim form, the authorization expired before the service date, the authorization does not match the billed service, or a retroactive authorization request was denied. The financial impact can be significant because payers may refuse to pay for the entire service when authorization is missing.

Common Causes

Cause	Frequency
Prior authorization not obtained before service The service required prior authorization from the payer, but no authorization was obtained before the service was rendered	Most Common
Authorization number not included on the claim Prior authorization was obtained but the authorization number was not included on the claim form, so the payer could not verify the authorization	Most Common
Notification or pre-treatment requirement not met The payer requires advance notification or pre-treatment review for the service, and this requirement was not fulfilled	Common
Authorization expired before service date The prior authorization was obtained but expired before the date the service was actually rendered	Common
Authorization on file does not match the service billed An authorization exists but for a different procedure, date range, or provider than what was billed on the claim	Common
Retroactive authorization request denied The provider attempted to obtain a retroactive authorization after the service was rendered, but the payer denied the retroactive request	Occasional

How to Resolve

Search for existing authorization Check your authorization tracking system and the payer portal for any authorization that covers this service.
Add authorization number and resubmit If found, add the authorization number to the claim and resubmit.
Request retroactive authorization If no authorization exists, submit a retroactive authorization request with clinical documentation.
Appeal for emergency services For emergencies, submit documentation of the emergency and request waiver of the authorization requirement.
File appeal promptly Be aware of payer-specific appeal deadlines. Some payers allow as few as 60 days.

Appeal Guide

Appeal with the authorization number and documentation if authorization was obtained. For emergency services, include documentation of the emergency. For non-authorized services, request retroactive authorization or provide medical necessity documentation supporting why the service should be covered. Be aware of payer-specific appeal deadlines — some payers allow as few as 60 days.

Common RARC Pairings

The RARC code tells you exactly what triggered the CO-197:

RARC	Description
N210	Alert: You may appeal this decision File an appeal within the payer's deadline — the payer is acknowledging your right to appeal the authorization denial →
N130	You may need to review plan documents or guidelines Review the payer's prior authorization requirements for this service to understand the basis for the denial →
N41	Authorization request denied The prior authorization request was specifically denied — review the denial reason and appeal with additional documentation →

How to Prevent CO-197

Implement a pre-service authorization verification workflow for all services that commonly require prior authorization
Maintain a current list of each payer's authorization requirements by procedure code
Verify authorization status before the date of service and confirm the authorization matches the planned service
Include the authorization number on every claim that required prior authorization
Track authorization expiration dates and renew before they expire
Use automated eligibility and authorization verification tools to check requirements in real time
Train front office staff to verify authorization requirements at scheduling and confirm before the patient arrives
For emergency services, have a process to notify the payer within the required timeframe after the emergency

Also Filed As

The same CARC 197 may appear with different Group Codes:

PR-197 OA-197

Related Denial Codes

CO-193 — Original Payment Decision Maintained on Review CO-174 — Service Not Prescribed Prior to Delivery CO-198 — Precertification/Authorization Limits Exceeded CO-210 — Pre-Certification/Authorization Not Received Timely CO-243 — Services Not Authorized by Network/Primary Care Providers