Precertification / authorization absent
The insurer says prior authorization was required but wasn't obtained.
Appeal goes to your insurer
If the service was emergent, cite the prudent-layperson standard — emergency care does not require prior auth under federal law. Otherwise argue the provider was responsible for obtaining auth, and request the balance be transferred back to the provider, not the patient.
- Request a fully itemized bill from the provider — not the summary statement.
- Match every line on the itemized bill to a line on your EOB. Charges that appear on one and not the other are the usual source of errors.
- Ask the insurer, in writing, for the specific plan provision behind the code.
- Note the appeal deadline printed on your EOB and diary it — missing it forfeits the appeal.
What does denial code CO-197 mean?
CO-197 means "Precertification / authorization absent". The insurer says prior authorization was required but wasn't obtained.
Do I have to pay a CO-197 charge?
Not necessarily. CO-197 is appealable in most plans. Ask for the written policy language behind the decision before paying, and file an internal appeal within your plan's deadline (often 180 days from the EOB date).
How do I appeal a CO-197 denial?
If the service was emergent, cite the prudent-layperson standard — emergency care does not require prior auth under federal law. Otherwise argue the provider was responsible for obtaining auth, and request the balance be transferred back to the provider, not the patient.
Where do I send a CO-197 appeal?
Appeal goes to your insurer. Use the appeals address printed on your EOB or the provider's statement, send it in writing, and keep a dated copy. If an internal appeal fails, most states also offer an independent external review.
How long do I have to appeal CO-197?
Most commercial plans allow 180 days from the date on the Explanation of Benefits for an internal appeal; Medicare and some employer plans differ. Check the appeal-rights section of your EOB and file early — missed deadlines are the most common reason appeals fail.
Let BillCheck write the CO-197 appeal for you
Upload your EOB and itemized bill. We decode every code, flag the errors, and draft a ready-to-send appeal letter addressed to the right office.
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BillCheck provides informational analysis only and is not legal, medical, or financial advice. Verify all details before submitting any correspondence to insurers or providers.