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CO-197CO-197 denial: what it means and how to fix it
CO-197 means the payer required prior authorization, precertification, or notification before this service was performed, and their records show it either wasn't obtained or doesn't match what was billed.
Common causes
- No prior authorization was requested before the service was rendered
- An authorization was obtained, but for a different procedure code, date, provider, or facility than what was actually billed
- The authorization expired before the service date, or the visit exceeded the authorized number of units/visits
- The authorization number wasn't included on the claim, so the payer's system couldn't match it
How to fix it
- Check your records (or the payer's provider portal) for an authorization number tied to this patient and date of service
- If one exists but wasn't on the claim, resubmit a corrected claim with the authorization number in the correct field
- If the authorization doesn't match the billed code, date, or units, contact the payer to see if it can be amended or if a retroactive authorization/appeal is possible
- If no authorization was obtained at all, check the payer's policy for a retro-authorization or peer-to-peer review process — some payers allow this within a limited window
Template pack letters for CO-197
- Retro-authorization request
- Appeal when an authorization was on file
General guidance only. Payer rules vary, so always check the payer's policy.
See the official X12 description