Denied for missing prior authorization
The plan required approval before this care, and its records show none. If the provider was in network, getting authorization was usually their job, and the CO group code means they generally can't bill you.
Official meaning (X12 code 197): Precertification/notification/authorization/pre-treatment absent.
Who pays
CO-197. Contractual obligation: the provider's contract with your plan makes this the provider's write-off. An in-network provider generally can't bill you for a CO amount.
What to do
- Check the group code: CO-197 usually means the in-network provider absorbs it.
- Ask the provider to request retroactive authorization.
- If it was an emergency, say so: emergency care can't require prior authorization under federal law.
- Appeal with the medical records showing the care was needed.
If you appeal
If care was already given, your provider can usually request retroactive authorization. Emergency care never needs prior authorization under the ACA. If you had no way to know approval was needed, or your provider was responsible for getting it, say so: in-network providers often can't bill you for their own authorization failures.
Deadlines for the first appeal
- employer plan
- 180 days from the notice
- ACA Marketplace plan
- 180 days from the notice
- Medicare Advantage plan
- 65 days from the notice
- Original Medicare
- 120 days from the notice
- Medicaid
- 60 days from the notice
The date printed on your notice controls. Urgent care can be appealed on an expedited (72-hour) basis.
What the data show
Averages across all denials; not a prediction for yours.
Appeal this denial
Upload your denial. We draft the appeal around this code, you approve it, and we fax it to your plan and mail a certified copy. Free check first, then $59.
General information, not legal or medical advice. Owed is a document-preparation and sending service, not a law firm.