CARC 197
No authorisation on file
The service required prior authorisation and the payer has none recorded.
Why you actually get this
- Authorisation was never obtained.
- It was obtained for a different code, date range or site than the one billed.
- It was obtained but the number was not carried onto the claim.
- The service drifted from what was authorised — a different procedure than requested.
How to check whether it’s correct
- 01Establish whether an authorisation exists at all before assuming it does not.
- 02Compare the authorised code, dates and site against what was billed.
- 03Check whether the authorisation number reached the claim.
Sometimes worth appealing
Where an authorisation exists and simply was not attached, this is a straightforward correction. Where the service drifted from what was approved, the appeal needs to establish the care was authorised in substance. Where none was obtained, retroactive authorisation is possible with some payers and not others — ask before writing off.
Often arrives with
Seeing a lot of these?
A single denial is a claim to work. A pattern of the same denial is a process to fix, and the two need completely different responses. A free panel reads ninety days of your claims data and shows which codes actually recur for you.
Claim Adjustment Reason Codes are maintained by X12 as External Code List 139. The official description of this code is theirs and is not reproduced here. Check the authoritative list for current wording and status.