Denial Code CO 197

Denial Code CO 197 also called as PR197 denial code – Payment adjusted for the absence of precertification/authorization

It is one of the most often and commonly scene denial. If claims submitted with no authorization for certain services as per patient plan, then those claims will be denied by insurance company with Denial Code CO 197 / PR197 denial code – payment adjusted for the absence of precertification/authorization.

As per insurance company certain services require an authorization from them before treating patient as per the patient insurance plan, so it’s billing expert responsibility to obtain authorization for those services before provider renders the treatment to patient.

In case if billing experts do not obtain authorization from an insurance company before providing the treatment, then those claims end up with no reimbursement from an insurance company.

There are two types of authorization as follows:

• Pre authorization/prior authorization – Obtaining authorization before providing the service.
• Retro authorization – Obtaining authorization after the treatment.

Note: Most of the insurance company only prefer pre authorization/prior authorization.

Denial Analysis:

“Emergency services doesn’t require a pre authorization”. You can verify the same on HCFA Box number 24 B, if the POS is 23 then those services rendered in an emergency unit.

When you come across CO 197 denial code / PR197 denial code, a first step is to check block number 24 B to verify where the services rendered for the patient. If the services rendered in an emergency care unit, then those claims don’t require an authorization. We need to reach insurance company by call and send those claims for reprocessing.

If services rendered is not an emergency, then we need to check the billing software application or check with rep for “prior authorization number” for the services rendered. If found and valid for the DOS, then reprocess the claim with that prior authorization number.

If not found, then check with insurance whether we can obtain “retro authorization”. Then get the phone number of the retro authorization department to obtain retro auth and also check the time limit to submit the corrected claim.

If retro authorization is not accepted, then check if you can “appeal the claim”. To do this, make sure you have the necessary medical records, fax number, appeal address, and appeal limit.

Finally, if appealed claim is withheld. Then assign those claims to client for necessary action i.e., “write off”.

Call action on Denial Code CO 119 / PR197 denial code– Maximum benefit exhausted/met:

1. May I know the claim received and denial date?
2. Check Box number 24B. If the place of service is 23, then request the rep to send the claim back for reprocessing stating emergency services doesn’t require an authorization.
3. If the Place of service other than 23, then check the billing software application or check with representative for prior authorization number.

• If valid prior authorization available for the DOS, then ask representative to reprocess the claim with that prior authorization number and get the reprocessing time.
• If prior authorization not available, then check with representative whether we can obtain retro authorization for the services rendered.

• If retro authorization is accepted from an insurance company, then get the telephone number of the retro authorization department and also time limit to submit the corrected claim. Next step is to reach insurance retro authorization department to obtain retro authorization for the services rendered. Once you have the retro authorization, then resubmit the claim as corrected claim with the obtained retro authorization.
• If retro authorization not accepted, then get the appeal address for appealing the claim. Make sure to obtain fax number, appeal address and get the time limit to appeal the claim.

• Get the denied EOB, Claim number and Call reference#
• Appeal the claim with necessary medical records and denied EOB.
• If appealed claim withheld, then write off those claims or assign those claims to client for further action.

Notes Format:

Called BCBS @ xxx-xxx-xxxx spoke with Chris for DOS 05/11/2023 and found claim was denied on 06/07/2023 as payment adjusted for the absence of precertification/authorization.” Please mention Action part here” Claim# 78947593473. Call ref# Chris08/25/2023.

Note: If you don’t have denied EOB then Requested the EOB through fax and mention the same in the notes

Action part:

Place of service is 23, then mention the following notes: “Checked application found place of service 23, informed the rep POS is 23(emergency care) and doesn’t require an authorization and sent the claim back for reprocessing. Reprocessing time is 20 business days, hence need to follow up after 30 business days”

Prior authorization available:” Checked application/rep found prior authorization number 7987783 and valid for DOS, hence sent the claim back for reprocessing. Reprocessing time is 20 business days, hence need to follow up after 30 business days”

Retro authorization:” Checked application/rep not found any prior authorization for the DOS. Checked with representative and found insurance accepts retro authorization and time limit to submit the corrected claim is 120 days from the DOS”.

Once you obtain retro auth, mention the following notes:

“Called retro authorization department @xxx-xxx-xxxx and obtained the retro auth# 6736363, updated retro auth and resubmitted the claim as corrected claim.”

Appealing the claim: “Checked with representative not found any prior authorization for the service billed, also retro authorization is not accepted by the insurance company.  Appeal address (PO Box xxxxx, ——-, xxxxx), fax number xxx- xxx-xxxx and time to appeal the claim is 90 days from date of denial. Hence appealed the claim along with medical records and denied EOB.

Write off/Assigned the claim to client: “Appeal received on xx-xx-xxxx(date) and withheld on xx-xx-xxxx(date), hence written off the charges.” or “Appeal received on xx-xx-xxxx(date) and withheld on xx-xx-xxxx(date), hence assigned the claim to client for further action.”

Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)