CO 197 Denial Code – Precertification/authorization/notification absent

Whenever claim denied with CO 197 Denial Code – Pre-certification/authorization/notification absent, it means authorization number is missing for the services rendered. In this case provider should submit the claim with authorization number to insurance company in order to get reimbursed.

First let us learn the term authorization in medical billing.

Authorization in Medical billing:

Authorization means physician has to obtain permission from insurance company for rendering certain medical services to patient.

If authorization has not obtained to treat those healthcare service, then claim will be denied (not paid) from an insurance company. So authorization is must to treat certain services to patient in order for provider to get reimburse the claim.

There are 2 types of authorization in medical billing:

  • Prior Authorization
  • Retro Authorization

Prior Authorization:

Prior authorization also called as Pre authorization. Physician has to obtain permission for certain health care services from the insurance company before rendering those services to patient, in order to get the claim reimbursed.

Retro authorization:

Physician can obtain permission for health care services from the insurance company after the services rendered to patient in order for claims get paid.

How to obtain Authorization in medical billing?

Physician is responsible to request authorization from insurance company with required documents for certain services.

Following information required to request authorization and requirement vary across insurances:

  • Patient Demographic information
  • Provider information
  • CPT/HCPCS Code and DX code

Once the insurance verifies the authorization requested from the healthcare provider. Insurance companies may either approve or deny the request.

If insurance company approves the authorization, then they provide the authorization number which needs to be included on block# 23 on CMS 1500 form.

If they deny the authorization request and suppose provider performed those health care services, then insurance company won’t reimburse those claims. (Note: If insurance company denies the authorization request, then provider has right to appeal the request with insurance company)

 

What if claim denied from insurance company with CO 197 denial code – Authorization number/pre-certification is missing or absent?

Whenever claim denied with CO 197 denial code, we need to follow the steps to resolve and reimburse the claim from insurance company:

  • First step is to verify the denial reason and get the denial date.
  • Next step verify the application to see any authorization number available or not for the services rendered.
  • If authorization number available, Call claims department and provide the authorization number and request representative to reprocess the claim.
  • If authorization number not available. Call and check representative whether we can obtain Retro authorization for the date of service. If yes, then obtain the details and request the retro authorization for rendered service.
  • If rep suggest retro authorization is not possible. Check whether you can appeal the claim with medical records, get fax number, mailing address, timely filing limit to appeal the denied claim.

 

Frequently asked questions:

  • On which block number in CMS 1500 form authorization number reported?

Authorization number should be reported on block number 23 in CMS 1500 form.

  • If service rendered as an emergency and claim submitted with Place of service 23, but received a denial as CO 97 denial code, what u will do in this case?

Place of service 23 is related to Emergency and for emergency services authorization is not needed. So if claim denied with CO 97 denial code, call the insurance company and request them to reprocess the medical claim.

  • Who has to get authorization from insurance company in medical billing?

Provider office has to get authorization or permission from Insurance Company.