How do I resolve a CO-197 denial?

Verify whether the payer's policy truly required prior authorization for this specific procedure, place of service, and patient plan. Check if the service was an emergency — if yes, most payers are required to cover emergency services regardless of prior auth. Request retroactive authorization from the payer or MBHO, providing clinical notes supporting medical necessity. If retro-auth is denied, file a formal appeal citing: (1) clinical necessity, (2) the patient's medical urgency, (3) any payer policy that allows retro-auth in this situation. Review whether the patient was adequately informed of the authorization requirement and document your office's pre-service auth workflow.

Can I appeal a CO-197 denial?

Yes. CO-197 denials are typically appealable with a 48% success rate. Resolution difficulty is Hard and typically takes 21-45 days.

835 Denial Combination

CO-197

Contractual Obligation · Claim-Level Adjustment

What This Combination Means

Prior authorization was required but was not obtained before the service was rendered. This is a hard denial — the service was rendered without a required authorization. Appeal success depends on whether retroactive authorization is possible, whether the patient had an emergency, or whether the service fell under a plan-specific exemption.

48%

Appeal Success

21-45 days

Avg. Resolution

Hard

Difficulty

Yes

Appealable

Step-by-Step Resolution

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

1
Verify whether the payer's policy truly required prior authorization for this specific procedure, place of service, and patient plan.
2
Check if the service was an emergency — if yes, most payers are required to cover emergency services regardless of prior auth.
3
Request retroactive authorization from the payer or MBHO, providing clinical notes supporting medical necessity.
4
If retro-auth is denied, file a formal appeal citing: (1) clinical necessity, (2) the patient's medical urgency, (3) any payer policy that allows retro-auth in this situation.
5
Review whether the patient was adequately informed of the authorization requirement and document your office's pre-service auth workflow.

Specialty Context

How CO-197 typically presents across different practice types.

Dental

Predetermination (not the same as prior auth) is often voluntary for dental. Confirm whether the payer's policy truly required prior auth or only recommended predetermination.

Medical

Prior authorization requirements vary by payer and procedure. For commercial payers, check the payer portal or call provider services to confirm whether retro-auth is available — many payers offer it for emergencies or admitted patients.

Behavioral Health

Behavioral health prior auth is often managed by an MBHO (like Optum Behavioral Health or Beacon). Contact the MBHO directly for retro-auth. For emergencies, retro-auth is typically available for the first 24-48 hours.

Individual Code References

View the standalone definition for each code in this combination.

CARC 197

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