How to fix a CO-197 denial
Find the approval, match it to the claim, or make the case for payment.
CO-197 means the payer found no precertification, authorization, notification or pre-treatment approval for a service that needed one. Check whether an approval exists, match it to the claim, ask for a retro-authorization where the plan allows it, or appeal.
- Meaning
- No approval on file
- Group code
- CO: not a patient balance
- First check
- Was an approval ever issued?
- Medicare appeal
- 120 days from the notice
What the CO-197 denial code means
Claim adjustment reason code 197 reads, in the official X12 list, "Precertification/authorization/notification/pre-treatment absent." In plain terms, the plan required an approval or an advance notice for this service, and nothing it could match to the claim was on file when the claim was processed.
The CO group code puts the adjustment on the practice under your contract, not on the patient. The Medicare Claims Processing Manual describes CO amounts as generally a write-off for the provider, not billed to the patient. That does not make the denial final: when an approval exists but never reached the claim, a corrected claim can fix it.
Read the codes around it. Reason code 198 means an approval exists but the service went past it, such as more units or visits than approved. Code 39 means the plan denied the request when it was made, 284 and 296 mean the number may be valid but does not apply to the billed service or to the provider, and 288 means a referral is missing. Remark codes such as M62 (missing or invalid authorization code) and N54 (claim inconsistent with the authorized services) point to a mismatch rather than no approval at all.
Our guide to reading denial codes explains how the group, reason and remark codes fit together.
Common causes of CO-197 and how to fix each
Find out which one applies before anything is resubmitted.
- Approved, but not on the claimPut the authorization number on the claim, in item 23 of the CMS-1500 or its electronic equivalent, and send a corrected claim.
- Expired before the date of serviceCompare the approved dates with the date of service. Ask the plan to extend or reissue the approval if it takes late requests; if not, appeal with the records.
- Wrong CPT or HCPCS code on the approvalCheck which code the chart supports. Ask the plan to update the approval to the code performed, or correct the claim if the claim was wrong.
- Wrong dates, units, site or providerAsk the plan to amend the approval to the actual dates, units, location or rendering provider, then resubmit.
- No authorization was requestedAsk whether the plan accepts a retro-authorization or retrospective review. If it does not, appeal only on solid grounds, such as an emergency.
- Coverage granted after the visitSome Medicaid programs accept a retrospective authorization within a set window after a retroactive eligibility decision. Send it with the claim.
- Emergency carePlans covered by federal emergency rules cannot require prior authorization for emergency services. Appeal with the emergency records.
Retro-authorization requests: when they work
A retro-authorization, also called a retrospective review, asks the plan to approve a service after it was given. There is no single rule: each plan sets whether it accepts them, for which services and how many days after the service, in its provider manual or your contract.
Some Medicaid programs accept them when coverage is granted after the fact. Virginia Medicaid, for example, requires a retrospective service authorization within 90 calendar days of the patient’s retroactive eligibility determination, sent with the claim, and denies late requests for timeliness.
Traditional Medicare’s prior authorization for certain hospital outpatient services does not take late requests. The CMS operational guide says the request must be made before the service and is not accepted after it. Claims without a provisional affirmation are denied unless CMS has exempted the provider, and so are related claims such as anesthesia and physician services. An affirmed decision is valid for 120 days.
Emergencies are different. Group health plans and insurers must cover emergency services without any prior authorization determination under 45 CFR 149.110, and Medicare Advantage plans must pay for emergency and urgently needed services regardless of prior authorization under 42 CFR 422.113. A CO-197 on emergency care is worth appealing with the records that show the emergency.
How we work a CO-197 denial
Read the full line
We check the remark code and whether the denial covers the whole claim or only some lines, units or dates.
Search for the approval
We look in the payer portal, your authorization log and the chart for an approval, a reference number or a notification.
Match it to the claim
We compare the number, codes, units, dates, site and rendering provider with what was billed.
Correct, request or appeal
A corrected claim if the approval exists, a retro request if the plan allows one, or a written appeal with the records.
Track it to payment
Each request or appeal goes on a calendar against the plan’s deadline and is followed up until paid or closed.
Fix the step that missed it
We change the scheduling or authorization step that let the service go ahead without a matching approval.
Preventing CO-197 before the visit
Every CO-197 has the same root: the approval and the claim did not meet. Our prior authorization team closes that gap before the visit, starting from the coverage confirmed by eligibility and benefits verification, because a request sent to the wrong plan is wasted:
- Check by plan, code and site of service whether approval is needed when the service is scheduled
- Log the authorization number, approved codes, units or visits, and valid dates where billers and schedulers see them
- Flag approvals nearing their end date or visit limit in time to request an extension
- Re-check the approval when the planned procedure, date or location changes
- Put the authorization number on the claim before it goes out
It means the plan required precertification, authorization, notification or pre-treatment approval for the service and found none on file that matched the claim. The CO group code puts the adjustment on the practice under your contract, not on the patient. It is not always final: check whether an approval exists, and whether its number, codes, dates and provider match what was billed.
Start by finding out whether an approval exists. If it does, correct the claim so the number, codes, units, dates and provider match it, and resubmit. If the approval does not cover what was done, ask the plan to amend it. If none was requested, ask about a retro-authorization, and appeal when the service was an emergency or the plan’s rules did not require approval.
Not while the amount carries group code CO, which puts it on the practice. For Medicare patients, CMS allows billing the beneficiary only for amounts under group code PR. For other plans, check your network contract before you bill a patient for a service that was denied because nobody obtained an approval.
CO-197 means no approval was on file. CO-198 means there was one, but the service went beyond it: more units, visits or days than the plan approved. For 198, ask the plan to extend the approval or approve the extra units, and set an alert so the next series of visits does not run past the approved total.
Look for a mismatch between the claim and the approval: the number left off the claim, a CPT code that changed during the procedure, a date outside the approved range, or a different provider or site billed. Fix the field that differs and resubmit. In Medicare Advantage, a plan that approved a service in advance may not later deny it for lack of medical necessity, under 42 CFR 422.138.
For Medicare, 120 days from receiving the initial determination to request a redetermination, with receipt presumed 5 days after the notice date, per the CMS appeals booklet. Other plans set their own appeal and retro-authorization windows, and some are short. Our denial management team calendars each denial against that payer’s deadline the day it posts.
Yes. We don’t list our clients on this site, but ask us and we’ll arrange it: with a current client’s permission, we share their contact details so you can hear how we work from them directly.
Send us your CO-197 denials.
We’ll check each one for an approval that never reached the claim, work what can still be recovered and show you where the gap is, free.