How to Appeal CO-197 Denial: Precertification/authorization/notification absent
The service required prior authorization that was not obtained before the date of service. This guide explains what it means, why it happens, and exactly how to build a winning appeal.
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What Does CO-197 Mean?
The service required prior authorization that was not obtained before the date of service.
Commonly seen in:
Step-by-Step Appeal Guide for CO-197
- 1
Locate any authorization number, date requested, or confirmation from the payer
- 2
Gather clinical documentation supporting the medical necessity of the service
- 3
Obtain records of any calls to the payer (dates, reference numbers, rep names)
- 4
Draft the appeal citing state retroactive authorization laws if applicable
- 5
Submit with documentation and follow up within 5 business days
Counter-Arguments to Use in Your Appeal
These are the strongest arguments medical billing professionals use to overturn CO-197 denials.
If auth was obtained, provide the authorization number and approved date range
If auth was sought but denied, include the denial and explain why services were still necessary
For emergencies, cite state laws allowing retrospective authorization
If the payer provided incorrect information about auth requirements, document the call (date, time, reference number, rep name)
Request retroactive authorization with medical necessity documentation
Regulations and Guidelines to Cite
Citing specific regulations strengthens your appeal and demonstrates you know your rights.
Expert Tip for CO-197 Appeals
This is one of the most overturnable denials. If you called the payer and were told auth wasn't needed, that call reference number is your strongest evidence.
Frequently Asked Questions
What is a CO-197 denial code?
The service required prior authorization that was not obtained before the date of service.
Can I appeal a CO-197 denial?
Yes. All insurance denials are appealable. Authorization denials can often be overturned with retroactive auth requests. Follow the step-by-step guide above and submit your appeal before the payer's deadline, typically 180 days from the denial date.
What documentation do I need to appeal CO-197?
For a CO-197 denial, you typically need: the original denial letter/EOB, clinical documentation supporting the service, any prior authorization records, and a cover letter citing the relevant regulations listed above. The specific documents depend on why the denial was issued.
How long does a CO-197 appeal take?
Most payers are required to process standard appeals within 30–60 days. Expedited appeals (for urgent care) must be decided within 72 hours. Under ERISA, group health plans must provide an appeal decision within 60 days for pre-service and 60 days for post-service claims.
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