CO-197 Denial Code
What it means
The care needed prior authorization (advance approval) and the insurer didn't have it on file, so it denied the claim.
Why it happens
Pre-approval wasn't obtained before the service, or it was requested but not recorded.
What to do
Ask your provider to request a retro-authorization and a peer-to-peer review. Appeal showing the care was medically necessary (and urgent, if applicable). ~65% of these are overturned.
Can you appeal it?
Yes - strong appeal candidate.
Official description
Precertification/authorization/notification/pre-treatment absent.
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