CO 197: Prior Authorization Absent
The payer says no prior authorisation was on file.
Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date.
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What CO 197 means
CO: Contractual obligation. The provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
The same code, a different prefix. 197 also arrives as PR 197. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says PR 197, read that page instead.
Is It Worth Appealing?
Usually recoverable. Appeal it. The money is usually there.
Why It Fires
In the order we see it.
No authorisation was requested before the service.
An authorisation existed but had expired before the date of service.
The CPT billed does not match the CPT on the authorisation.
Authorisation was obtained under a different plan or payer than the one billed.
How to Appeal CO 197, Step by Step
Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date.
- 1Step 1: Read the remark code. Find the remark code printed next to CO 197 on the 835 or EOB. It says what the payer wants back.
- 2Step 2: Find the cause. Match the denial to one of the 4 causes in Why It Fires above, and fix that one.
- 3Step 3: Take the first action. Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date.
- 4Step 4: Attach the documentation. The authorisation number and its approval date. The retro-authorisation request and the payer's response to it. Documentation that the service was urgent or emergent, where the payer waives auth for those.
- 5Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window. See what an appeal letter must contain and the filing limits by payer.
The common mistake. Do not appeal before checking whether a retro-authorisation window is still open. Retro-auth is faster, higher yield and does not spend the appeal.
Free: the Denial Code Appeal Playbook. 53 codes on one sheet: appeal, fix and resubmit, or let it go, and what to attach. Get the playbook
CO 197 description
The payer says no prior authorisation was on file.
The payer says no prior authorisation was on file. So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
This is our plain-English wording, not the official X12 text. X12 asserts copyright over the published descriptions, so we write our own and say what it means for the money rather than restating the code.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Your Questions Answered
What does CO 197 mean?
The payer says no prior authorisation was on file. Contractual obligation. The provider absorbs it and cannot bill the patient.
Can you appeal CO 197?
Usually recoverable. Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date.
Why does CO 197 happen?
No authorisation was requested before the service. An authorisation existed but had expired before the date of service. The CPT billed does not match the CPT on the authorisation. Authorisation was obtained under a different plan or payer than the one billed.
What documentation wins a CO 197 appeal?
The authorisation number and its approval date. The retro-authorisation request and the payer's response to it. Documentation that the service was urgent or emergent, where the payer waives auth for those.
How do I appeal a CO 197 denial?
Step 1: Read the remark code. Find the remark code printed next to CO 197 on the 835 or EOB. It says what the payer wants back. Step 2: Find the cause. Match the denial to one cause: No authorisation was requested before the service. An authorisation existed but had expired before the date of service. The CPT billed does not match the CPT on the authorisation. Authorisation was obtained under a different plan or payer than the one billed. Step 3: Take the first action. Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date. Step 4: Attach the documentation. The authorisation number and its approval date. The retro-authorisation request and the payer's response to it. Documentation that the service was urgent or emergent, where the payer waives auth for those. Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window.
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