CARC 197CO · Contractual Obligation

Required prior authorization, precertification, or notification wasn't obtained before the service was rendered or the claim was submitted.

Common causes
The provider's office didn't secure authorization before performing the service, or the authorization request wasn't submitted or completed in time.
Suggested fix
Determine if a retroactive authorization is possible; if not, appeal with documentation of medical necessity and urgency, and improve pre-service authorization workflows going forward.

Related Contractual Obligation codes

107This claim depends on another related claim or service being referenced, but that link wasn't provided.11The diagnosis code doesn't support medical necessity for the procedure billed, based on the payer's coverage edits.13The claim shows a date of service after the patient's recorded date of death.146The diagnosis code billed wasn't a valid, active code as of the date of service.150The documentation submitted doesn't justify the complexity or level of the service billed, commonly seen with evaluation and management visit levels.16The claim is missing required information or contains a billing error that prevented the payer from processing it.170This payer doesn't reimburse this specific provider type for this service.171This payer doesn't cover this service when it's billed by this provider type in this particular facility setting.

Frequently asked questions

What does CARC 197 mean?

Required prior authorization, precertification, or notification wasn't obtained before the service was rendered or the claim was submitted.

How do I resolve CARC 197?

Determine if a retroactive authorization is possible; if not, appeal with documentation of medical necessity and urgency, and improve pre-service authorization workflows going forward.

Why does CARC 197 happen?

The provider's office didn't secure authorization before performing the service, or the authorization request wasn't submitted or completed in time.

CARC codes maintained by X12 (x12.org). Descriptions on this site are original reference interpretations. Always verify codes with authoritative sources before making billing decisions.