What Is CARC 197?
CARC 197 indicates a denial because precertification, authorization, or notification required by the payer was not obtained before the service was rendered, often paired with RARCs identifying the specific authorization missing.
- Eliminate CARC 197 denials at the front-end by building a payer-specific prior-auth requirement matrix into scheduling.
- Real-time eligibility (270/271) responses often include auth requirements.
- Each CARC 197 denial should trigger a root-cause review: was auth required, was it requested, was it received, was the auth number on the claim?
CARC 197
Also known as: Denial Code 197; Precertification/Authorization/Notification absent
CARC 197 indicates a denial because precertification, authorization, or notification required by the payer was not obtained before the service was rendered, often paired with RARCs identifying the specific authorization missing.
Definition
CARC 197 is the standard X12 code for prior-authorization denials. Most commercial payers and Medicare Advantage plans require prior authorization for advanced imaging (MRI, CT, PET), inpatient admissions, surgeries, specialty drugs, behavioral health visits beyond a threshold, and DME. CARC 197 appeals depend heavily on the timing — many payers will accept a retro-authorization for emergent or urgent services if requested within a payer-specific window (often 24-72 hours from service). Outside that window, the denial often becomes provider write-off or patient-responsibility (with proper notice).
Common Causes of CARC 197
- A service that requires prior authorization — advanced imaging (MRI, CT, PET), inpatient admission, surgery, specialty drugs, behavioral-health visits beyond a threshold, or DME — was performed without obtaining it.
- Authorization was obtained, but the auth number was missing from the claim or did not match the service billed.
- A Medicare Advantage or commercial plan's authorization requirement was not caught at scheduling or check-in.
How to Resolve CARC 197
- Run a root-cause check on the claim: was authorization required, was it requested, was it received, and was the auth number on the claim?
- If you are within the payer's retro-authorization window (often 24-72 hours from service for urgent/emergent cases), submit a retro-auth request with clinical documentation.
- If clinically supported, request a peer-to-peer review with the payer's medical director to overturn the denial.
- If outside the window with no authorization, bill the patient only where a valid ABN-equivalent advance notice was given; otherwise the balance is a provider write-off.
How to Prevent CARC 197 Denials
- Build a payer-specific prior-authorization requirement matrix into scheduling so auth needs are flagged before the service is rendered.
- Use real-time eligibility (270/271) checks, which often return the payer's authorization requirements.
- Capture and verify the authorization number on the claim before submission.
Example
An MRI brain (CPT 70551) for a Humana Medicare Advantage patient denied CARC 197 because no prior auth was obtained. If retro-auth window (typically 1-2 business days) has not passed, the practice may submit a retro-auth request with clinical documentation. If past the window, the denial is typically a provider write-off unless an ABN-equivalent notice was given to the patient.
Common Misconceptions
CARC 197 denials are not always lost revenue — many payers accept retro-authorization within 24-72 hours of service for urgent/emergent cases. Even in non-urgent cases, peer-to-peer review with the payer's medical director sometimes overturns the denial.
Practical Application
Eliminate CARC 197 denials at the front-end by building a payer-specific prior-auth requirement matrix into scheduling. Real-time eligibility (270/271) responses often include auth requirements. Each CARC 197 denial should trigger a root-cause review: was auth required, was it requested, was it received, was the auth number on the claim?
Related Terms
Prior Authorization
Prior authorization is the payer's process of pre-approving a planned service, procedure, medication, or admission before it is rendered, based on medical-necessity criteria; without an approved PA where required, claims typically deny under CARC 197.
Read definition arrow_forwardCARC
A Claim Adjustment Reason Code is a standardized code maintained by the X12 External Code List committee that explains why a claim line was adjusted (paid less than billed, denied, or transferred to patient responsibility) on a payer's 835 ERA.
Read definition arrow_forwardCARC 50
CARC 50 indicates the payer denied a claim because it determined the services were not medically necessary based on its medical-necessity policy, LCD, NCD, or commercial medical-policy criteria.
Read definition arrow_forwardCARC 97
CARC 97 indicates the payer denied or reduced payment because the service is bundled with another service on the same claim under NCCI Procedure-to-Procedure edits — 'The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.'
Read definition arrow_forwardWhere This Applies on MedPrecision
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