Authorization/Precertification Absent or Exceeded
The payer required prior authorization for this service and either did not receive one at all (CO-197) or the billed service/units/dates exceed what was actually authorized (CO-198).
Guided troubleshooter available for this denial
Answer a few questions to reach the correct disposition. No patient or claim identifiers requested.
In plain language
The payer required prior authorization for this service and either did not receive one at all (CO-197) or the billed service/units/dates exceed what was actually authorized (CO-198).
Start here
Pull the authorization from the payer portal; compare authorized CPT, units, dates, and provider to what was billed.
Who resolves it
Precertification/Prior Authorization, Billing/Follow-Up
Who prevents it
Precertification/Prior Authorization — authorization-to-CPT validation before scheduling/performing the service.
How to resolve this denial, step by step
- 1
Pull the authorization from the payer portal; compare authorized CPT, units, dates, and provider to what was billed.
- 2
If a mismatch is only a claim data-entry issue, correct and resubmit.
- 3
If no authorization exists, determine whether the payer allows retro-authorization requests and the applicable time window (payer-specific).
- 4
If retro-authorization is denied or unavailable, evaluate whether a medical-necessity appeal or write-off is appropriate.
- 5
Document authorization findings and outcome.
- 6
Escalate if there is a documented authorization on file that the payer's system does not show (potential payer processing error).
Then choose the correct disposition
Corrected claim
when a valid authorization exists but was not properly submitted.
Retro-authorization request
when no authorization was obtained; success is payer- specific and not guaranteed.
Medical-necessity appeal
when retro-authorization is denied and clinical documentation supports the service.
Write-off
when none of the above succeed and no patient-billing exception applies.
Stop and escalate when
- Clinical documentation shows the authorized plan of care was necessarily modified mid- procedure; authorization discrepancy between provider and payer records; repeated payer authorization system errors; medical necessity dispute.
What Needs to Be Corrected
- Claim correction: If a valid authorization exists but was omitted or mis-entered, add the correct number and resubmit as a corrected claim.
- Upstream correction: If no authorization was obtained, or the wrong CPT/units were authorized, the precertification workflow must request a retro-authorization (payer- specific — not guaranteed to be granted) or the claim must be adjusted to match what was actually authorized.
Do Not Do This
- Do not fabricate or backdate an authorization number.
- Do not bill the patient for a missing-authorization denial where the payer contract or state/federal rule places that liability on the provider.
- Do not change the CPT code merely to match what was authorized if the code does not reflect the service actually performed.