Denial Code CARC 197: Precertification or Authorization Absent

CARC 197 means the service required precertification, prior authorization, or notification, and the payer has no record of it. It is recoverable more often than practices assume, because payers grant retroactive authorization in defined circumstances and because the requirement itself is sometimes applied in error.

What this denial means

The payer is saying this service was on its precert or prior-authorization list and no valid authorization was on file at the time of service. It is a process denial, not a judgment that the care was unnecessary.

Why it happens

Either the authorization was never obtained, was obtained but not linked to the claim correctly, expired before the date of service, or the payer wrongly applied a precert requirement that did not attach to this plan or this code. Emergencies and services where eligibility could not be verified in advance are common false positives.

The appeal angle that works

First check whether authorization was actually required for this plan and code, because it is sometimes applied in error. If it was required and missed, request retroactive authorization, which many payers grant for emergencies, retroactive eligibility, or when the member could not be identified at the time of service. Document why prior authorization was not feasible and cite the plan provision that allows the retro request.

Questions

Can a prior authorization denial be overturned after the fact?

Often, yes. Many payers grant retroactive authorization for emergencies, for retroactive eligibility situations, or when the member could not be identified at the time of service. The appeal has to document why prior authorization was not feasible.