Denial codes / CO-197
CO-197 denial: meaning, fix & appeal letter template
Payer has no prior authorization on file.
What it means
Official CARC 197 descriptionPrecertification/notification/authorization/pre-treatment absent.
The payer requires prior authorization for this service and found none linked to the claim. Often the auth exists but wasn't attached to the claim, or it covered a different code, date range, or provider.
Common causes
- Authorization obtained but number not on the claim
- Auth covered a different CPT, units, or date range than what was performed
- Auth issued to a different rendering provider or facility
- Urgent/emergent service performed before auth could be obtained
- Auth requirement missed at scheduling
How to fix it
- Search the payer portal and your records for an existing auth number
- If the auth exists, resubmit or appeal with the auth number attached
- If the code changed intra-procedure, request an auth update / retro-auth (many payers allow it within a few days)
- If the service was emergent, appeal with documentation of urgency
- Add auth checks to scheduling for this payer/CPT combination
Appeal or corrected claim?
Depends on whether an auth exists. Auth on file but missing from the claim: corrected claim or reconsideration with the auth number. Code changed or emergency: request retro-authorization or appeal with clinical urgency. No auth and no exception: usually not recoverable from the payer — check your contract for patient-billing restrictions.
Medicare Advantage note
For Medicare Advantage plans, 42 CFR 422.138(c) provides that if the MA organization approved the service through prior authorization, it may not later deny coverage on the basis of lack of medical necessity. 42 CFR 422.101(b)(6) also requires MA plans to follow traditional Medicare coverage criteria. Verify the current regulation text before citing.
What to attach
- Authorization confirmation (number, date issued, approved codes and dates)
- Portal screenshot or call reference if the auth was obtained by phone
- Physician order and clinical notes
- Documentation of urgency (for emergent services)
CO-197 appeal letter template
Replace every [BRACKETED] field. Remove any optional paragraph that doesn't apply.
[PRACTICE NAME] [ADDRESS] · [PHONE] · NPI [NPI] · TIN [TIN] [DATE] [PAYER NAME] Attn: Appeals / Provider Disputes [PAYER APPEALS ADDRESS] Re: Request for Reconsideration — Claim [CLAIM NUMBER] Patient: [PATIENT NAME] Member ID: [MEMBER ID] DOB: [DOB] Date of Service: [DOS] CPT: [CPT CODE] Billed: [AMOUNT] Denial: CO-197 — Precertification/notification/authorization/pre-treatment absent. Dear Appeals Reviewer, We request reconsideration of the denial of the above claim. The above service was denied with CARC 197, indicating authorization was absent. Prior authorization was obtained on [AUTH DATE] under authorization number [AUTH NUMBER] for CPT [CPT CODE], valid [START DATE] through [END DATE]. The authorization number was not transmitted with the original claim. A copy of the authorization confirmation is enclosed. [If the procedure changed: During the procedure, [REASON], requiring CPT [NEW CPT] instead of the authorized [AUTH CPT]. The enclosed operative note documents the clinical decision.] [For Medicare Advantage: Under 42 CFR 422.138(c), a service approved through prior authorization may not be denied on the basis of medical necessity.] Based on the enclosed documentation, we request that [PAYER NAME] overturn this denial and reprocess the claim for payment in accordance with the member's benefits and our participation agreement. Enclosures: - Authorization confirmation (number, date issued, approved codes and dates) - Portal screenshot or call reference if the auth was obtained by phone - Physician order and clinical notes - Documentation of urgency (for emergent services) Please contact [CONTACT NAME] at [PHONE] or [EMAIL] with any questions. Sincerely, [NAME], [TITLE] [PRACTICE NAME]
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