Very CommonContractual Obligation (CO)Prior Authorization
CO-197: Precertification/authorization/notification absent
A required precertification, authorization, or notification was not obtained for this service. This is closely related to CO-15 but specifically references the absence of precertification or notification rather than a mismatch with an existing authorization.
Common Causes
- Precertification or prior notification was required but never requested
- Service was performed as urgent/emergent but notification was not provided within the required timeframe
- Authorization was requested but not yet approved when the service was rendered
- Payer requires notification even when full PA is not needed, and notification was missed
How to Resolve CO-197
- 1Determine if the payer accepts retroactive authorization requests
- 2If retro-auth is available, submit with clinical documentation
- 3If the service was emergent, appeal with documentation of the emergent circumstances
- 4Request a peer-to-peer review with the payer medical director
- 5File a formal appeal with a letter of medical necessity
How to Prevent CO-197 Denials
- Check PA and notification requirements for every scheduled service
- Use automated PA requirement checking tools that flag services needing authorization
- Establish a workflow for emergent notification within payer-required timeframes
- Train scheduling staff to initiate PA requests at the time of scheduling
Related Denial Codes
Stop Denials Before They Happen
Greenlight automatically checks prior authorization requirements and submits PA requests before the service is rendered -- eliminating authorization denials entirely.
See How It Works