PR-197: Precertification/Authorization/Notification Absent
The patient owes for the unauthorized service. Check if authorization can still be obtained before collecting from the patient.
What Does PR-197 Mean?
With PR (Patient Responsibility), the patient is financially responsible for the service because authorization was not obtained. This occurs when the payer assigns the cost of unauthorized services to the patient, particularly when the patient obtained care without following the plan's referral or authorization process.
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 |
|---|---|
| Patient responsible for unauthorized service cost The service was not preauthorized and the payer holds the patient financially responsible for the cost of the unauthorized service | Most Common |
| Patient did not follow referral/authorization process The patient obtained the service without following the plan's required referral or authorization process | Common |
How to Resolve
- Verify if authorization can be obtained Determine if the service can still be authorized retroactively.
- Appeal on the patient's behalf If authorization was obtained or can be secured retroactively, appeal with documentation.
- Communicate with the patient If the service cannot be authorized, inform the patient of their financial responsibility and available payment options.
Appeal on behalf of the patient if authorization was obtained or if retroactive authorization can be secured. Include the authorization documentation and medical necessity records.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-197:
| RARC | Description |
|---|---|
| N210 | Alert: You may appeal this decision The patient or provider may appeal the authorization denial → |
| N130 | You may need to review plan documents or guidelines Review the plan's authorization requirements to determine if the service can still be authorized → |
How to Prevent PR-197
- Educate patients about their plan's authorization requirements and the importance of following the referral process
- Verify authorization before the patient's visit and inform them if authorization has not been obtained
- Help patients understand that services without authorization may result in full financial responsibility
Also Filed As
The same CARC 197 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/197
- https://www.athelas.com/tbh/avoiding-carc-197-denials-precertification-strategies-for-medical-providers
- https://www.codingahead.com/denial-code-197/
- https://medsolercm.com/blog/co-197-denial-code-guide
- https://med.noridianmedicare.com/web/jadme/topics/ra/denial-resolution/n210-197
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.