835 Denial Combination

CO-197+N386

CO

Contractual Obligation · Claim + Service Level Adjustment

Authorization

What This Combination Means

The service was denied because required precertification, authorization, or notification was not obtained before the service was rendered. The denial is based on a National Coverage Determination policy that establishes coverage criteria including authorization requirements. The provider must write off the amount and cannot bill the patient due to contractual obligations with the payer.

Financial Responsibility

provider writeoff

The provider must absorb this amount as a contractual write-off and cannot transfer the balance to the patient, even though the denial resulted from the provider's failure to obtain required authorization.

NaN%

Appeal Success

30-60 days (appeal process)

Avg. Resolution

Hard

Difficulty

Yes

Appealable

Step-by-Step Resolution

Steps tailored specifically to this CO-197+N386 combination — not generic advice.

Appealable:Authorization denials are appealable if the provider can demonstrate that authorization was obtained but not recorded correctly, or if the service was emergent and authorization requirements should be waived.
  1. 1

    Retrieve the specific National Coverage Determination cited in the denial

    Access the NCD at www.cms.gov/mcd/search.asp to verify the authorization requirements and coverage criteria that were not met

  2. 2

    Verify authorization status in your tracking system and payer portal

    Confirm whether authorization was actually obtained but not referenced on the claim, or if the service was truly rendered without required precertification

  3. 3

    If authorization exists, submit appeal with authorization number and approval documentation

    Include evidence that authorization was obtained prior to service and met the NCD requirements, requesting claim reprocessing

  4. 4

    If no authorization exists but service was emergent or urgent, prepare appeal with clinical documentation

    Demonstrate medical necessity and circumstances that justify waiver of prior authorization requirements under the NCD policy

  5. 5

    If authorization was not obtained and no exception applies, accept the write-off and update authorization workflows

    Implement process improvements to verify NCD authorization requirements before rendering similar services in the future

Specialty Context

How CO-197+N386 typically presents across different practice types.

Dental

Medical

Common for services covered under Medicare NCDs such as durable medical equipment, certain surgical procedures, diagnostic tests, or specialty therapies that require prior authorization even when the service itself is covered by the NCD policy

Behavioral Health

May apply to intensive outpatient programs, partial hospitalization, or other behavioral health services covered under NCDs that require precertification or notification before services are rendered

Individual Code References

View the standalone definition for each code in this combination.

CARC 197RARC N386

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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