835 Denial Combination

CO-197+N285

CO

Contractual Obligation · Claim-Level Adjustment

Authorization

What This Combination Means

The claim was denied because required precertification, authorization, notification, or pre-treatment approval was not obtained or submitted. The payer is additionally noting that the referring provider name was missing, incomplete, or invalid, which may have prevented proper authorization verification or tracking. Both issues contributed to the denial under contractual obligations.

Financial Responsibility

provider writeoff

The provider must write off the denied amount per contractual agreement with the payer and cannot balance bill the patient for this authorization-related denial.

92%

Appeal Success

30-60 days (appeal process)

Avg. Resolution

Hard

Difficulty

Yes

Appealable

Step-by-Step Resolution

Steps tailored specifically to this CO-197+N285 combination — not generic advice.

Appealable:Authorization denials marked CO are appealable if the provider can demonstrate that authorization was obtained or was not required, or if the referring provider information issue prevented proper authorization processing.
  1. 1

    Verify authorization status in payer portal and internal tracking system

    Determine if authorization was obtained prior to service and whether the referring provider name discrepancy affected authorization approval or claim processing

  2. 2

    Correct referring provider information in claim system

    Ensure referring provider NPI, name, and credentials match payer enrollment records and authorization documentation exactly

  3. 3

    Submit appeal with authorization documentation and corrected referring provider information

    Include authorization approval letter, referral documentation with complete and accurate referring provider details, and explanation linking the data issue to the authorization processing failure

Specialty Context

How CO-197+N285 typically presents across different practice types.

Dental

Dental precertification denials often occur for major services (crowns, implants, orthodontia) when referring general dentist information is missing on specialist claims

Medical

Common in specialist claims requiring referrals (orthopedics, cardiology, pain management) when PCP or referring physician information is incomplete or mismatched with authorization records

Behavioral Health

Frequently seen in therapy or psychiatric claims when referring psychiatrist, PCP, or EAP counselor information is absent or doesn't match the authorization referral source

Individual Code References

View the standalone definition for each code in this combination.

CARC 197RARC N285

Medicare Contractor Guidance for CARC 197

Noridian + uhc + aetna + bcbs_az

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 to Prevent CARC 197 Denials

  • ✓

    Obtain prior authorization for item, prior to delivery

  • ✓

    Ensure to append 14-byte UTN provided within the affirmative decision letter to the claim

  • ✓

    If prior authorization is being bypassed, ensure the special modifiers required are appended to the claim line

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Synthesized from official definitions — not from training data

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