Denial code · group CO
CO-197: No authorization, precertification or notification was on file for the service
Short answer
CO-197 means the payer required authorization, precertification or notification before the service and found none linked to the claim. Often the approval exists and the number is missing from the claim or tied to a different provider, code or date; that takes a corrected claim. When nothing was requested, the route is a retro-authorization request where the plan allows one, then an appeal with the clinical record.
Look up other codes in the denial code library.
Last reviewed by the Remitwright billing team. Editorial policy
Group CO means contractual obligation: the balance is written off, not billed to the patient. The number is the reason; the two-letter group says who carries the balance.
Remark codes that usually come with CO-197
- M62
- The treatment authorization code on the claim is missing, incomplete or not valid
- N54
- What was billed does not match what was precertified or authorized
Common causes
Nobody requested the authorization
The scheduler assumed the service did not need one, the payer added the code to its authorization list mid-year, or the service was added during the visit after the approved plan was set. The payer processes the claim, finds no approval on file for that member and code, and denies the whole line.
The authorization exists but is not on the claim
The number sits in the patient's chart or the auth tracker and never reached the 837P. The prior authorization field is blank or holds a referral number instead. The payer's system matches on the number, so a blank field looks like no approval.
The authorization is for a different provider, date or code
Approval obtained under one NPI or tax ID while the claim goes out under another; a date of service a day outside the approved window; a code billed that was not on the approval because the clinician changed the plan. N54 is the usual companion.
The secondary payer wanted its own authorization
Medicaid plans and some commercial secondaries require their own approval even when the primary paid. The secondary claim goes out with the primary's adjudication and comes back CO-197 because nothing was requested from the secondary.
The payer's requirement list changed
Payers add and remove codes from their authorization lists, often at the start of a quarter or a plan year. A practice working from last year's list keeps scheduling the service without an approval until the first denial arrives.
How to fix it and resubmit
- 1
Find out whether an authorization exists before you respond
Check the auth tracker, the payer portal and the referral. If an approval covers the member, provider, code and date, this is a claim error. If one covers some of those but not all, it is an amendment problem. If none exists, it is a retro request.
- 2
Corrected claim when the number was missing or wrong
Put the authorization number in the prior authorization field and resubmit with frequency code 7 and the original claim number. Check the number format the payer expects; some systems drop letters or leading zeros.
- 3
Amend the authorization when the details do not match
Ask the payer to add the code, extend the dates or correct the provider on the existing approval. Many allow changes within a window after the service. Once the amendment posts, resubmit the denied line with the same number.
- 4
Request a retro-authorization when none was obtained
Payers allow retro requests in limited situations: emergencies, coverage not known at the time, or a member who did not disclose the plan. Send the clinical notes with the request and name the reason the approval was not obtained. If approved, resubmit; if denied, move to appeal.
- 5
Appeal with the record and the payer's own rule
Attach the documentation of medical necessity and, where it applies, the payer's authorization list showing the code was not on it for that date. An appeal without a retro-authorization attempt first is usually returned with a note to request one.
How to prevent it
- An authorization check at scheduling by payer, code and place of service against the payer's current list, with the list refreshed each quarter
- Authorization number, approved codes, units and dates stored in the practice management system so the number flows onto the claim automatically
- A scrubber hold on any authorization-required code where the prior authorization field is blank
- A reconciliation of approved codes against the charges when the clinician changes the plan of care, before the claim goes out
A CO-197 on an added service in ABA therapy
An ABA provider holds an authorization for technician-delivered treatment hours for a child. During the month the supervising analyst adds a parent training session, which is a different code. The claim for that session returns CO-197 with N54, because the code is not on the approval. The biller asks the plan to add the code to the existing authorization. The plan allows amendments within a set number of days after service and backdates it. The line is resubmitted with the authorization number and pays. This is a hypothetical example.
Official text: the X12 claim adjustment reason code list. The meaning above is our paraphrase for billers; the list is the authority.
FAQ
Questions about CO-197
Does CO-197 mean the service is not covered?
Can I get an authorization after the service?
Can I bill the patient for a CO-197 denial?
The authorization was approved. Why did the claim still deny CO-197?
Is CO-197 appealable?
Next step
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