CO-197 — Prior authorization absent
Claim-adjustment reason code 197 · typically reported as CO-197
What it means
The item required precertification/prior authorization and the claim has none on file. The most preventable expensive denial in DME.
Why DME claims hit it
- Items on Medicare’s DMEPOS Required Prior Authorization List delivered without an affirmed PA decision
- MA/commercial PA rules missed at intake (every plan differs)
- PA obtained but never linked to the claim
How to fix it
- Screen every order against the payer’s PA list before scheduling delivery
- If a PA decision exists, resubmit with the tracking/UTN number in the right field
- For Medicare required-PA items delivered without one: payment denial is automatic — evaluate retrospective options per contractor guidance, tighten intake
Appeal posture
Appealable for good-cause scenarios on some plans; mostly this is a process-prevention problem.
Related denial codes
CO-15 — Authorization number missing or invalidCO-198 — Authorization exceededCO-252 — Attachment / documentation required
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