CO-197: Precertification or authorization was missing

Why this denial happens

• The provider's office forgot to submit the prior auth, or submitted it after the service.
• An auth was issued but for a different CPT code, date, or facility than what ended up being billed.
• The service was emergent and the payer's urgent-auth exception wasn't invoked on appeal.
• The plan changed auth requirements mid-year and the provider used outdated rules.

How to fix or appeal CO-197

1. Confirm in writing whether the missing auth is on the provider or the payer - billing offices often agree to write off CO-197 rather than balance-bill you.
2. If the service was emergent, cite your plan's prudent layperson / emergency-services rule when appealing.
3. Ask the provider to submit a retroactive authorization request with clinical justification.
4. If retro auth is denied, file a member appeal arguing the service met medical necessity and the auth gap was administrative.

Related denial codes

• CO-50 - Not medically necessary
• CO-204 - Service not covered under the plan

Insurer-specific appeal guides

• How to appeal a medical necessity denial from Aetna
• How to appeal a out-of-network denial from UnitedHealthcare
• How to appeal a prior authorization denial from Cigna