Quick Explanation
Denial code 197 (CO-197) indicates that a claim was denied because the required pre-certification, prior authorization, or notification was not obtained or documented before the service was rendered. This code is distinct from other denials (such as CO-204 for non-covered services) because it is specifically administrative—meaning the service itself may be covered, but payment is withheld due to missing or incorrect authorization documentation, not clinical ineligibility.
Common Causes for 197
Denials with code 197 typically happen for the following specific reasons:
- Prior authorization was not obtained from the payer before the service was provided.
- Authorization number was missing or incorrectly entered on the claim form.
- Service was performed after the authorization period expired or outside the approved timeframe.
- Required pre-treatment notification or documentation (e.g., Unique Tracking Number) was not appended to the claim.
- Provider was unaware of updated payer requirements or changes in pre-authorization policies for specific CPT/HCPCS codes.
How to Prevent 197 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Verify pre-authorization requirements for each CPT/HCPCS code and patient insurance plan before scheduling or delivering services.
- Obtain and document the authorization number and validity period, and ensure it is included on every claim submission.
- Implement a pre-claim checklist that includes confirmation of active authorization and correct payer-specific modifiers.
- Regularly review and update internal protocols to reflect changes in payer pre-authorization policies and requirements.
- Train staff to communicate with payers and patients to confirm authorization status and document all correspondence.
Appeal Letter Template for 197
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 197 - Pre-certification Absent
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code 197: "Pre-certification Absent".
The denial of this claim under code CO-197 is based on the absence of documented pre-certification; however, the service provided was medically necessary and clinically appropriate as supported by the patient’s diagnosis and documented treatment plan. The provider has since obtained and submitted the required authorization retroactively, and the payer’s own policy allows for retroactive review and payment when authorization is secured post-service due to administrative oversight. Furthermore, the service aligns with the payer’s coverage criteria and was rendered within the scope of the patient’s benefit plan. Therefore, in accordance with payer policy and CMS guidelines regarding retroactive authorization, this claim should be reconsidered and paid as the clinical and contractual requirements have been satisfied.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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