CO-197: Precertification/Authorization/Notification Absent
CO (Contractual Obligation)What is CO-197?
CO-197 is a Contractual Obligation code indicating the required precertification, prior authorization, or notification was not obtained before the service was rendered. This is one of the top 5 denial codes by volume across all commercial payers. 92% of providers report that prior auth delays patient care.
Why Does CO-197 Occur?
- Prior authorization not obtained before the service. The payer requires pre-approval for the procedure, and it was not on file.
- Authorization expired. The auth was obtained but the service was performed after the authorization's valid date range.
- Authorization for a different procedure or provider. The auth on file does not match the procedure code, provider NPI, or facility billed on the claim.
- Notification deadline missed. Some payers require notification within 24-48 hours of an emergency admission even when prior auth is not required.
How to Fix CO-197 Denials
- Check the payer's auth requirements for the specific CPT code. Confirm whether auth was needed and, if so, whether one was obtained.
- If auth was obtained but the claim was denied, verify the auth number, procedure code, provider, and date range match the claim exactly.
- Request retroactive authorization if the payer allows it. Many payers permit retro auth within 24-72 hours of emergency services.
- Appeal with clinical documentation, the auth reference number (if available), and evidence that the service was medically necessary.
CO-197 by Payer
| Payer | Common RARC | Appeal Deadline | Notes |
|---|---|---|---|
| UnitedHealthcare | N/A | 60 days from remittance | UHC's prior auth list is updated quarterly. Check uhcprovider.com for current requirements. |
| Anthem | N/A | 365 days from denial notice | Anthem allows retro auth within 72 hours for emergency admissions. |
| Aetna | N/A | 180 days from denial | Aetna publishes auth requirements by CPT code on their provider portal. |
| Cigna | N/A | 180 days from denial | Cigna requires auth for most outpatient surgeries and advanced imaging. |
| Medicare | N/A | 120 days (redetermination at MAC) | CMS mandates 72-hour expedited PA response by Jan 2026. Digital PA APIs required by Jan 2027. |
Related CARC Codes
If you are seeing CO-197, check these related codes: CO-21 (required authorization absent), CO-23 (prior auth not obtained), CO-50 (non-covered service).
Common Questions About CO-197
Can I get retroactive authorization?
Some payers allow retro auth for emergency services, typically within 24-72 hours. Check the payer's policy. Elective procedures without prior auth are much harder to authorize retroactively.
What is the difference between CO-197 and CO-23?
Both relate to missing authorization. CO-197 specifically means precertification or notification was absent. CO-23 means the prior authorization was not obtained. In practice, payers use them interchangeably, but CO-197 may also apply to notification requirements for emergencies.
Altair catches CO-197 denials before submission with prior auth requirement checking. See how pre-submit claim scoring works.