CO-197 denial code
Precertification, authorization or notification absent
How to fix it
Request retroactive authorization immediately — many payers permit it within a limited window. Otherwise appeal with clinical documentation supporting medical necessity.
How to prevent it
Verify authorization requirements at scheduling, not at check-in. Authorization denials arrive after the cost of care is already sunk.
In practice
An advanced imaging study is performed on a referral marked urgent. The claim returns CO-197 — precertification, authorisation or notification absent.
The referring practice believed it had initiated authorisation; the imaging centre assumed the referring practice had completed it. Neither confirmed, and the study went ahead on the strength of an assumption.
The service was clinically appropriate, was performed competently, and is unpayable. Retroactive authorisation is granted by some payers in narrow circumstances, usually involving genuine emergency, but is not generally available for elective imaging.
What sits behind it
CO-197 differs from CO-15 in a way that matters operationally. CO-15 means an authorisation exists but does not match; CO-197 means none was obtained at all. The first is often recoverable, the second frequently is not.
Authorisation issues are the third-largest denial category industry-wide at 12.8% according to Optum's analysis of 124 million claim remits, and they concentrate in services where responsibility is split between an ordering practice and a performing one — imaging, surgery, infusion, durable medical equipment.
The structural fix is to stop treating authorisation as the referring party's responsibility. Whoever bills the claim bears the loss, which means whoever bills should verify that authorisation is actually on file rather than assumed, at the point the service is scheduled.
Related codes
Terms used here — Prior Authorization · Denial · Appeal
How we handle it — Prior Authorization · Eligibility Verification · Denial Management
Primary sources
The rules behind CO-197, at the bodies that publish them.
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) (opens in a new tab)
Centers for Medicare & Medicaid Services — The rule imposing prior authorization decision timelines and API requirements on impacted payers. It is the single largest scheduled change to authorization workflow this decade.
- Medicare Coverage Database (LCD/NCD) (opens in a new tab)
Centers for Medicare & Medicaid Services — Searchable national and local coverage determinations. The direct answer to whether a diagnosis supports medical necessity for a given procedure.
- Medicare Claims Processing Manual (opens in a new tab)
Centers for Medicare & Medicaid Services — The operative manual for how Medicare claims must be coded, submitted, adjusted and appealed. When a payer policy and a vendor's advice disagree, this settles it.
Every denial code with a guide
Authorization
Bundling
Contractual
Coverage
Data quality
Documentation
Eligibility
Liability and workers comp
Patient responsibility
Provider eligibility
Timely filing
Looking for a different code? Search all 190 CARC and RARC codes
Questions about CO-197
CO-197 means no authorisation was obtained at all. CO-15 means one exists but does not match the claim — wrong dates, codes, provider or facility. CO-15 is frequently recoverable by supplying the correct details; CO-197 usually is not, because payers rarely grant authorisation retroactively.
Some payers allow it in narrow circumstances, most commonly genuine emergencies or cases where eligibility was not knowable at the time. It is not generally available for elective services, and relying on it as a fallback is not a workable process.
Nominally the ordering practice, but the party that bills the claim bears the financial loss when it was not obtained. That asymmetry is why the performing practice should confirm authorisation is on file rather than assume the referring party completed it.
Optum's analysis of 124 million claim remits puts authorisation issues at 12.8% of denials, the third-largest category. They concentrate in services where responsibility is split between an ordering and a performing practice.
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