CARC Code
197
Precertification/authorization/notification/pre-treatment absent.
45%
Recovery Rate
21-60 days
Avg. Resolution
Hard
Difficulty
Common
Frequency
Recommended Action
Obtain retroactive authorization or appeal with emergency/urgent care documentation
Step-by-Step Resolution
- 1
Verify whether prior authorization was actually required for this service on this date
- 2
Check if an authorization was obtained but the number was not included on the claim
- 3
Resubmit the claim with the authorization number in the appropriate field (Box 23 on CMS-1500)
- 4
If auth was not obtained, call the payer to request retroactive authorization with clinical justification
- 5
For emergency situations, use emergency auth exception process and document urgency in clinical notes
- 6
Implement authorization tracking system to prevent future CARC 197 denials
Common Remark Codes (RARC)
These RARC codes often appear alongside CARC 197 on remittance advice.
Payer-Specific Notes
How major payers handle CARC 197 in practice.
Delta Dental
Pre-treatment estimates (PTEs) required for procedures over $300; PTE ≠ authorization
Cigna Dental
Major restorative and ortho require pre-authorization; verify auth requirement before scheduling
Common 835 Combinations
CARC 197 most often appears with these Group Code + RARC combinations on 835 remittances.
Appeal Letter Template
Enter your email to access the full appeal template for CARC 197.
Free · No spam · Unsubscribe anytime