197Denial Code (CARC)Active
CARC 197 Denial Code - Fix Missing Preauthorization
CARC 197 means the claim was denied because a required precertification, authorization, notification, or pre-treatment approval was not obtained. This adjustment indicates that the payer needs specific documentation or prior approval before providing coverage for the service.
Who Pays: Group Code Liability
With CO, the provider must write off the amount and cannot bill the patient. If PR is applied, the patient can be billed for the denied service. The correct group code depends on the payer's policy regarding authorization requirements.
Why Claims Get Code 197
- The service was provided without obtaining prior authorization from the payer.
- The authorization number was not included on the claim submission.
- The authorization request was submitted but not approved before the service date.
- The authorization was for a different service or provider than what was billed.
- The payer's records do not show any notification or authorization for the service.
How to Fix & Resubmit
- Verify whether prior authorization is required for the service with the payer.
- Check if an authorization was obtained and if the correct authorization number is on the claim.
- Contact the payer to confirm if the authorization was linked to the claim correctly.
- If authorization was never obtained, discuss options with the payer, such as retroactive authorization.
- Submit a corrected claim with the proper authorization details if applicable.
Corrected Claim or Appeal?
Submit a corrected claim if authorization details were omitted or incorrect. If authorization was not obtained, appealing may require demonstrating that the service met medical necessity or was emergent, if the payer allows.
Preventing Future 197 Denials
- Ensure that all services requiring prior authorization are identified before scheduling.
- Implement a checklist to confirm authorization numbers are included on claims.
- Regularly train staff on payer-specific authorization requirements.
- Use an EHR system that flags services needing pre-authorization.