What does CO-197 mean?
CARC code 197 is a prior authorization denial, meaning the service required pre-authorization that was not obtained. This is a very common denial in behavioral health because many payers require authorization for therapy sessions beyond a certain number. First, check if the service actually required authorization — some payers exempt certain CPT codes or initial evaluations. If authorization was obtained, submit proof (auth number, approval letter). If not, attempt a retroactive authorization request, which many payers allow especially for urgent or emergent services. Include clinical documentation supporting why the service was necessary. Success rate is approximately 40%.
How to appeal CO-197
Check the RARC code
The RARC (Remittance Advice Remark Code) on your ERA provides specific details about why the claim was denied. This tells you exactly what needs to be fixed.
Gather clinical documentation
Compile clinical notes, treatment plans, and any relevant guidelines that support the medical necessity of the service provided.
Submit a formal appeal letter
Write a detailed appeal letter that references clinical guidelines, payer policies, and includes supporting documentation. Submit via the payer's preferred method (fax, portal, or mail).
Key notes for behavioral health
Attempt retroactive authorization. Otherwise appeal with proof of existing auth or that service type doesn't require it.