CO-197: Preauthorization absent

What CO-197 means

The service required prior authorization and the payer found none on file.

What it usually means in a chiropractic office

Common with plans that route chiropractic through a benefits manager where visits beyond an initial allowance need authorization. The auth often exists and simply never made it onto the claim.

How to work it

1. If an auth exists, add the authorization number to the claim and resubmit.
2. If no auth was obtained, request retroactive authorization from the payer; many benefit managers allow a window.
3. Fix the intake step so auth requirements are caught at eligibility, before the first visit.

What this looks like in practice

A patient with a managed chiropractic benefit uses their initial allowed visits, and visit seven requires an authorization the front desk never requested. Three claims go out before the first CO-197 lands. The authorization is granted retroactively, the claims are resubmitted with the auth number, and everything pays, minus three weeks of delay that a pre visit check would have avoided.

How to stop it from happening again

• ✓Capture preauthorization requirements during eligibility, before the first visit
• ✓Track visit counts against authorized allowances so the renewal request goes out before the visit that needs it
• ✓Record auth numbers on the case so they flow onto claims automatically

General information for billing teams, not legal or payer specific advice. CARC definitions belong to X12; payer policies vary and control. Verify against the payer contract before acting on any individual claim.