CO-197 denial code
The payer found no authorization on file for this service, or none it could match to the claim.
“Precertification/authorization/notification/pre-treatment absent.”
Start 10/31/2006 · Last modified 05/01/2018 · X12 adjustment reason code list
What it usually means in behavioral health
In behavioral health, CO-197 usually means one of three things: the authorization was never requested, it was requested from a different payer or behavioral health administrator than the one billed, or it exists but the claim does not match it.
Weekend and after-hours admissions to detox, residential, and PHP are the classic source, because the stay starts before anyone can reach the payer. Level-of-care changes are the second: a step-down from PHP to IOP usually needs its own authorization.
Common causes
- Admission started before the authorization was requested, such as a weekend residential or detox admission
- Authorization obtained from the medical plan when behavioral health is carved out to a separate administrator, or the reverse
- Claim billed under a different NPI, tax ID, or site than the authorization names
- Level of care changed (for example, PHP to IOP) without a new authorization
- Authorization number left off the claim or keyed with a typo
Correct and resubmit, or appeal?
If an authorization exists, this is a correction: make the claim match the authorization record and resubmit or send a corrected claim under the payer's rules. If none exists, check the plan's retro-authorization and late-notification rules before appealing; an appeal generally needs proof the authorization was obtained, requested in time, or not required.
What to do
Pull the authorization record: number, payer or administrator, provider, level of care, codes, units, and dates.
Compare it field by field with the claim. The mismatch is usually the provider, the dates, or the level of care.
If everything matches, ask the payer to link the authorization and reprocess, and note the call reference.
If no authorization exists, check whether the plan allows retro-authorization or late notification, and its deadline.
Log the root cause (never requested, wrong payer, or mismatch) so the intake or utilization review step that missed it gets fixed.
Often seen with
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