Denial code CO 197 defines in Medical Billing as “Pre-Authorization/Pre-certification/notification missing”. In revenue cycle management or Medical Billing when patient get treatment from from a doctor or provider or from hospital, in some case patient should need prior approval before the treatment. If that approval is not provided with claim, then claim denied due to pre-auth is absent.
In emergency cases or accidental cases, approval or authorization letter is required after the treatment within a certain time period and this is called “Retro-Authorization”.
How to handle Pre-Authorization denial on claim?
When received denial code CO 197 as Pre-Authorization or notification absent, we have to follow certain steps which mentioned below,
Step 1-
- Check the EOB for what is mentioned over there with CO-197 denial code. Most of the time exact which document required for no-auth denial.
- Check the patient old medical records and claim if there is any Authorization number available, if yes then need to call insurance and confirm authorization number is valid for DOS or not. What is active and inactive date of authorization number.
- If Auth number is valid then need to update on present claim and resubmit to insurance.
Step 2-
- While checking on EOB and older DOS and claims of patient not found any authorization number, check any hospital claim of the patient is available , if not then call to insurance company and ask for providing Authorization number, if they provide then update and resubmit corrected claim with auth number.
- If no authorization number found then ask to insurance executive that if any patient hospital claim is over there with auth number, if found then resubmit and if not found then
- Ask for Retro Authorization number for claim in emergency or accidental case.
Note- If provider is out of network in that case Authorization responsibility is patient but if provider is in-network then its providers or hospital’s responsibility to get the authorization for performing any such type of service.