CO-197: Prior authorization absent

What causes CO-197?

• Authorization was never obtained because nobody checked whether the code required one
• Authorization was obtained but the number was not put on the claim
• The authorization covered a different CPT code than the one performed
• The service went beyond the number of units or visits the authorization allowed
• The authorization expired before the date of service
• The rendering provider on the claim is not the one named on the authorization

How do you fix a CO-197 denial?

1. Pull the authorization record and compare four things against the claim: the CPT code, the units, the date range and the rendering provider
2. If a valid authorization exists and simply was not transmitted, correct the claim and resubmit rather than appealing
3. If the authorization covers a different code, check whether the payer allows a retro-authorization and how many days you have — the window is often as short as 72 hours after service
4. If it was genuinely never obtained, file a retro-authorization request with the clinical documentation showing medical necessity, and expect to lose some of these
5. Log the reference number and the name of the person who confirmed it, every time

Can CO-197 be prevented?

This denial is almost entirely preventable: the chart can be clean and the care right, and the claim still goes unpaid because a check was never made. The fix is a person who checks the authorization requirement before the visit rather than a person who discovers it afterwards.

A denial like this one is the recurring cost that medical billing outsourcing is built to take off your desk — a dedicated seat working the queue instead of it waiting for whoever has a free hour.

Codes worked the same way

CO-197 is taken back to the authorization. So are these, which is why a queue sorted by recovery route moves faster than one sorted by code number — the same person, in the same system, with the same evidence to hand, clears all of them in one pass.

• CO-198 — Authorization limit exceeded
• CO-288 — Referral absent
• CO-15 — Authorization number missing
• CO-39 — Authorization already refused
• CO-272 — Coverage guidelines not met
• N54 — Claim does not match the authorization

Specialties that name this among their costliest

These are specialties whose own worst denials include one of this kind. The line under each is the denial they name, quoted from their page so you can see what the link is based on.

• Ambulatory Surgery Centers
  Prior authorization obtained for the surgeon but not the facility
• Behavioral Health
  Authorization units exhausted mid-course without renewal
• Urology
  Prior authorization missing for advanced imaging
• Radiology
  Advanced imaging denied for missing prior authorization
• Ophthalmology
  An injection given after the drug authorization lapsed, or under an authorization written for a different agent than the one actually drawn up that day.
• Neurology
  Long-term video EEG authorized as an ambulatory home recording but performed as an admission to the epilepsy monitoring unit, so the facility days sit outside the authorization

What leaving it costs

Working a denied claim costs $57.23 per denied claim in administrative time (source) — before any of it is recovered, and whether or not it ever is.

Payers ultimately pay roughly 90% of claims even while using an initial denial to slow payment (source), so the reason one sits is rarely that nobody knows how to work it. Put your own denial count in.

Questions

Code descriptions are the standard X12 claim adjustment reason and remittance advice remark code text. Payer policies differ, and the payer’s own coverage policy governs any individual claim. This page is working guidance, not legal or clinical advice.