The prior authorisation checklist that prevents CO-197

Why this denial is different

Most denials are arguments about whether a service was justified. CO-197 is not an argument — the payer is saying it required permission and cannot find any. The chart can be perfect and the service can be clinically necessary and the claim still does not pay.

That makes it the only major denial category that is almost entirely eliminated by process rather than by appeal. Once it has happened, your options are a retro-authorisation inside a window that is sometimes as short as 72 hours, or a write-off.

The six checks

Run these before the visit, not after. The order matters — each one is cheaper than the one after it.

Does this CPT code require authorisation for this plan?

Not for this payer — for this plan. Two patients with the same insurer can have different requirements. Check the plan, and check it again in January when half your patients change plans.

Is the authorisation on file for the code actually being performed?

Authorisations are issued against specific codes. A procedure that changes in theatre, or a code that shifts after the coder reviews it, invalidates the approval that was obtained.

Does the unit or visit count cover what is planned?

An authorisation for six visits does not cover the seventh, and nobody notices until the remittance arrives.

Is the date of service inside the authorisation window?

Reschedules are the usual culprit. The authorisation was obtained for a date that moved, and the window closed.

Is the rendering provider the one named on the authorisation?

Cover arrangements break this constantly. The authorisation names a provider; a colleague performs the service; the claim is denied.

Is the number actually on the claim?

The most irritating version of this denial: a valid authorisation exists, and it was never transmitted. That one is corrected and resubmitted rather than appealed.

What to do when it has already happened

Pull the authorisation record and compare four things against the claim: code, units, date range, rendering provider. If a valid authorisation exists, correct the claim. If it covers a different code, ask about retro-authorisation immediately and get the answer in writing. If nothing was ever obtained, submit the clinical documentation and expect to lose some.