CO-197: Precertification/authorization/notification absent

CO-197 says the service required prior authorization and the plan did not receive one. The result is a denial of a service that was already delivered. This is one of the more frustrating denials because it is a paperwork problem, not a clinical one.

What your letter emphasized

• Whether prior authorization was actually required for your service under the plan document (many plans overreach)
• Whether the provider did request prior authorization (portal timestamp, phone call log, or approval letter)
• Whether the service qualified for an exception to prior authorization (emergency, urgent care, out-of-area travel)
• The retrospective medical necessity of the care

What the insurer's likely response is

Reversal on evidence of prior authorization request. If the provider can show they requested prior authorization and the plan lost or misrouted it, the plan usually reverses.

Retrospective approval on medical necessity. For urgent or emergency situations, plans have policies allowing retrospective approval when the care could not have been delayed for prior authorization.

Upheld denial citing plan requirement. The plan says prior authorization was required and none was submitted.

Recoded to medical necessity. Sometimes the plan drops the prior-auth argument but denies for medical necessity anyway.

How to handle each outcome

Reversal: confirm reprocessing.

Retrospective approval: confirm the plan's letter approves the specific claim and that reprocessing is underway.

Upheld: file second-level appeal. If the service was urgent, argue urgent-care exception. If the provider tried to get prior authorization, attach evidence.

Recoded: handle the new denial (usually CO-50, medical necessity).

Urgent-care exception

Under 29 CFR 2560.503-1(m)(1) for ERISA plans, and similar provisions for other regimes, prior authorization cannot be required for urgent care where a delay could seriously jeopardize the member's health. Emergency services in particular are protected under ACA 42 USC 300gg-19a: plans must cover emergency services without prior authorization.

If your care was truly urgent or emergency, cite these authorities in the appeal.

Was prior authorization actually required

Read the plan document. Prior authorization requirements are usually listed in a schedule or an appendix. If the service is not on the list, the plan should not deny for CO-197. Provider directories and portal alerts sometimes overstate what requires prior authorization.

The provider's role

Ask the provider's billing office:

• Was prior authorization requested for this service?
• If yes, when and through what channel (portal, phone, fax)?
• Do they have a confirmation number or portal screenshot?
• Was an approval received?
• If no request was made, why not?

If the provider did request prior authorization and can produce evidence, that is a strong appeal.

What if no prior authorization was requested at all

• If the service was urgent or emergency, invoke the exception
• If the service should not have required prior authorization under the plan document, argue that
• If the plan's portal was broken or the provider was misinformed by the plan, argue estoppel
• If none of those apply and the care was routine and non-urgent, this is a hard appeal

What to gather

• Provider's portal screenshots or logs showing prior-authorization attempts
• Approval or denial letters if any were received
• Chart notes showing urgency or emergency
• Plan document showing whether prior authorization was required for the specific service
• If the plan portal was down or misrepresented requirements, screenshots

When to escalate

External review under ACA section 2719 works for CO-197 denials with a medical judgment component (was the care truly urgent, was it medically necessary). State DOI complaint is right for plans that overreach on prior-authorization requirements.

Prevention

For future planned care, always confirm prior authorization requirements before the service. Ask the provider's office to show you the approval letter. Do not rely on portal alerts alone.