co 197 denial code meaning and description

CO 197 Denial Code – Pre-Certification or Authorization not Present (2024)

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Have you received a CO 197 denial code from the insurance provider officials, and you are confused because you are not sure what it is? There are so many questions that come to one’s mind, and this is very natural.

“Denial Code CO-197 means- Precertification/authorization/notification absent“

Well, if you have been getting a code of this kind, then no need to worry about it, as you’ll receive all the relevant information down below.

What are the basics of the CO 197 Denial Reason Code?

In order to understand the meaning of the CO-197 denial code, one must be aware of the basics of it. There are insurance service providers who ask to obtain prior authorization before surgery or any other costly health services.

If the authorization is not received before the service that is to be performed, then the insurer would not be able to reimburse the process. Some of the services which need authorization include surgical processes, high-cost ancillary services, and more.

However, this totally depends on different circumstances when the services take place. The need for prior authorization also has the potential to delay the required healthcare. So yes, it truly depends on the circumstances.

This overall process can affect both the patient and the satisfaction coming from the health services. Also, it is important to let you know that it is not the responsibility of the Surgeon or the patient to obtain the authorization.

Moreover, according to the basics of the denial code CO-197, the authorization can be received retroactively with the help of the insurers.

Furthermore, it is a fact that avoiding obtaining the preauthorization can lead to less reimbursement and lower benefits for the patients. Hence, even if the patient is not responsible for obtaining the authorization, they still need to check through the processes.

What does it mean if you receive a CO-197 Denial Code?

If you have received the Co197 denial code, then it probably means you have lost a good portion of the reimbursements. In other words, when there are unauthorized claims, then they bring huge revenue losses along for the patient.

So it is recommended to initiate the verification process after the patient is scheduled for the health care procedure.

How can one take the preauthorization?

Once the patient has been scheduled for the health care service procedure, then it is suggested to initiate the verification process. After that make sure to enquire with the insurance service provider to ensure if the service needs a pre-authorization or not.

If the insurance company says yes, then it is required to initiate the request which may need multiple pieces of information. This includes the personal details of the patient, insurance status, information of the facility where the procedure is to be performed, diagnosis along with ICD codes, and more.

Furthermore, it is a matter of fact that the solid pre-authorization would need a correct CPT code. So it is going to be a challenge to determine the real code before the health care service is offered.

Frequently Asked Questions-FAQs

Q1. What is preauthorization?

Ans. Advance notice is always needed to the insurance officials by the physicians or surgeons before the company agrees to pay for the medications and the related procedures.
If the authorization is not received, then the insurance companies would not reimburse the process.

Q2. What does “CO” mean in the CO 197 Denial reason Code?

Ans. The CO in the denial code co-197 means Contractual Obligations, where the provider is financially liable.
In the medical field, the code comes with a particular number that is related to a particular issue, and in this case, it is 197.

Q3. Is it important to submit the medical note at the time of taking pre-authorization?

Ans. Yes, it is. When the insurance company says that preauthorization is needed, then multiple information is to be submitted along with the medical note including the patient’s personal details, the current status of the insurance, details of the facility where the health care service is to be performed, diagnosis details with ICD codes and much more.

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