What does denial code CO-197 mean?

CO-197 means: The claim was denied because the required approval or notification was not obtained from the insurance company before the service was provided. The payer needed to be notified or asked for permission ahead of time, but this step was not completed.. Prior authorization 14-byte Unique Tracking Number (UTN) was not appended to claim Special modifier to bypass the prior authorization process was not appended to claim line. This HCPCS code requires prior authorization

How do I resolve a CO-197 denial?

Correct claim and rebill with the 14-byte UTN provided within the affirmative decision letter If billing on CMS-1500 claim form, include UTN in Item 23 See full Medicare contractor resolution steps at tryarceum.com.

Can I appeal a CO-197 denial?

Yes. Most CO-197 denials can be appealed within 60-180 days depending on payer. This is appealable if the authorization was actually obtained but not referenced on the claim, if it was an emergency service, or if the payer failed to communicate the authorization requirement. Use our free tool to generate an appeal letter.

CARC Code

197

🔴 Hard Denial

Missing Prior Authorization or Notification

The claim was denied because the required approval or notification was not obtained from the insurance company before the service was provided. The payer needed to be notified or asked for permission ahead of time, but this step was not completed.

authorization

Resolution: 45%Hard difficulty21-60 days avg

How to resolve this denial

Which payer denied this claim?

▶✓ Pre-action checklist — verify before contacting the payer

Was prior authorization obtained? Check your PMS for an auth/reference number.
If auth exists, verify the auth number was included on the claim submission.
Check if the auth was for the correct date of service and procedure code.
Confirm the rendering provider NPI on the claim matches the authorized provider.

▶More about CO-197 — stats, related codes, appeal template

45%

Recovery Rate

21-60 days

Avg. Resolution

Hard

Difficulty

Common

Frequency

Payer-Specific Notes

How major payers handle CARC 197 by specialty.

UnitedHealthcare

Auth list changes quarterly; verify current auth requirements at uhcprovider.com

Aetna

Aetna requires auth even for some outpatient procedures; use NaviMedix portal

BCBS

BCBS Availity portal lists all services requiring auth; subscribe to payer alerts for updates

Common 835 Combinations

CARC 197 most often appears with these Group Code + RARC combinations on 835 remittances.

COCO-197The claim was denied because required precertification, authorization,Appealable COCO-197+N285The claim was denied because required precertification, authorization,Appealable COCO-197+N95The payer denied the claim because required precertification or authorizationAppealable COCO-197+M21This denial indicates that authorization was missing for a service provided inAppealable COCO-197+N386The service was denied because required precertification, authorization, orAppealable COCO-197+N210Prior authorization 14-byte Unique Tracking Number (UTN) was not appended to

Look up any combination →

Appeal Letter Template

Generic appeal template for CARC 197 denials.

We are appealing denial of claim [CLAIM_NUMBER] under CARC 197. Authorization number [AUTH_NUMBER] was obtained on [AUTH_DATE] for [SERVICE]. This number was inadvertently omitted from the original claim submission. We are resubmitting with the authorization number in field 23 and request reconsideration.

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